Narcan isn’t universally free, and insulin isn’t entirely unregulated in price, but the gap between them is real and frustrating for the millions of Americans who depend on insulin daily. The short answer comes down to three things: how each drug is funded, how each drug is made, and how the market around each one is structured. Narcan’s free distribution is largely paid for by government grants and opioid lawsuit settlements, while insulin remains trapped in a pricing system shaped by patent strategies, middlemen, and limited competition.
How Narcan Gets Distributed for Free
When you pick up free Narcan at a community health center or harm reduction program, someone is paying for it. That someone is usually the government. Federal agencies like the Substance Abuse and Mental Health Services Administration fund naloxone distribution as part of the national response to the opioid crisis. States run their own programs on top of that. California’s Naloxone Distribution Project, launched in 2018, has provided free naloxone to all 58 counties and reported over 400,000 overdose reversals.
A major funding source that didn’t exist a decade ago: opioid litigation settlements. Pharmaceutical companies and distributors that fueled the opioid epidemic have paid billions in legal settlements, and states are directing portions of that money toward naloxone. Illinois, for example, approved $4.5 million in opioid remediation funds specifically for its “Access Narcan” program and another $3 million for other overdose reversal drugs. These settlement dollars essentially create a dedicated revenue stream for free distribution that has no equivalent in the diabetes world.
Regulatory changes also make distribution easier. All 50 states now allow people to obtain naloxone without an individual prescription. Thirty-three states have statewide standing orders, meaning any pharmacy can hand it out under a blanket prescription from a state authority. This infrastructure was built specifically to get naloxone into as many hands as possible, as fast as possible, because every dose potentially prevents a death within minutes.
Why Insulin Is So Expensive to Begin With
Insulin has been around for over a century, which makes its price tag seem absurd. But unlike naloxone, which is a relatively simple chemical compound, insulin is a biologic drug produced by living organisms rather than standard chemical reactions. This biomanufacturing process is more complex and less consistent, which raises production costs and creates barriers for competitors. Bringing a biologic drug to market can cost as much as $250 million.
That complexity is why generic competition, the force that drives down prices for most older drugs, has barely touched insulin. Most non-biologic generics cost about 80% less than the brand-name version. The only “generic” insulin available so far was made by a company already dominant in the insulin market, and it’s only 15% cheaper than the patented product. The difference is enormous.
Three companies control the global insulin supply. Eli Lilly, Novo Nordisk, and Sanofi together hold over 90% of the global insulin market by value. That level of concentration gives manufacturers outsized power over pricing, and it limits the competitive pressure that would normally bring costs down over time.
How Patents Keep Competition Out
Insulin manufacturers have used a range of legal strategies to extend their market exclusivity far beyond what the original patents would allow. The core tactic is called evergreening: as old patents expire, companies file new ones covering tweaks to the drug’s formulation, delivery method, or manufacturing process. These secondary patents don’t necessarily make the drug work better, but they add years of monopoly protection.
Companies also build what’s known as patent thickets, layering multiple overlapping patents on the same product so that any generic competitor would have to challenge each one individually. The legal cost of doing so is enormous. In some cases, brand-name manufacturers have paid generic companies directly to delay entering the market, a practice known as pay-for-delay. In others, they’ve pulled older versions of their insulin off the market and marked them as obsolete in pharmacy databases, making it impossible for pharmacists to substitute a cheaper version even when one technically exists. This practice, called product hopping, forces patients and insurers onto the newer, more expensive product.
The Middlemen Who Profit From High Prices
Even beyond manufacturing and patents, insulin pricing is inflated by pharmacy benefit managers, the companies that negotiate drug prices between manufacturers and insurance plans. PBMs earn rebates and fees calculated as a percentage of a drug’s list price. The higher the list price, the larger the rebate, and the more the PBM earns. This creates a perverse incentive: PBMs favor drugs with higher sticker prices because those generate bigger payments.
In September 2024, the Federal Trade Commission sued major PBMs for artificially inflating insulin prices through exactly this mechanism. According to the FTC, manufacturers raised their list prices specifically to offer the larger rebates that PBMs demanded in exchange for formulary access. The result is a feedback loop where list prices climb higher and higher while the actual amount paid (the “net price”) is lower but still opaque to patients, especially those without insurance or with high-deductible plans who pay based on the inflated list price.
The $35 Cap and Who It Covers
The Inflation Reduction Act, passed in 2022, capped insulin copays at $35 per month for people on Medicare. Starting in January 2023, Medicare enrollees in prescription drug plans began paying no more than $35 for a month’s supply of each covered insulin product, and Part D deductibles no longer apply to insulin. By mid-2023, the cap extended to Medicare Part B and Medicare Advantage coverage for insulin used with traditional pumps.
The catch is significant: this cap only applies to Medicare beneficiaries. People with private insurance, those on Medicaid in states without their own caps, and uninsured Americans are not covered by the federal law. Some manufacturers have voluntarily capped out-of-pocket costs, and several states have passed their own $35 or similar caps for privately insured residents. But there is no universal price protection for insulin the way there is a universal push to distribute naloxone for free.
The Real Difference: Emergency vs. Chronic
The fundamental reason these two drugs are treated so differently comes down to how the healthcare system categorizes them. Naloxone is framed as an emergency intervention, a single dose that reverses an overdose in minutes. Governments treat it like a fire extinguisher: get it everywhere, make it free, and worry about cost later. The opioid crisis created political urgency, lawsuit money, and bipartisan support for wide distribution. Naloxone is also cheap to produce. California secured a twin-pack of generic naloxone nasal spray for $24 through its CalRx program, roughly 40% below typical market prices.
Insulin, by contrast, is a chronic medication that millions of people need every day for the rest of their lives. It’s more expensive to manufacture, sold through a complex supply chain with multiple profit-taking intermediaries, and protected by aggressive patent strategies. There’s no equivalent of opioid settlement funds earmarked for insulin. There’s no standing-order system to hand it out at pharmacies without a prescription. The political and legal infrastructure that makes free Narcan possible simply doesn’t exist for insulin.
That doesn’t make the situation fair. A person with Type 1 diabetes who rations insulin because of cost faces a life-threatening emergency every single day, not just once. The difference isn’t about which drug matters more. It’s about which crisis generated the political will, the legal settlements, and the regulatory shortcuts to make free access possible.