“That was my first warning,” Isela said. She contacted her insurance agent and was told her application was denied because something on her medication list indicated that Isela uses drugs. Isela, a registered nurse who works in an addiction treatment program at Boston Medical Center, scanned her med list. It showed a prescription for the opioid-reversal drug naloxone — brand name Narcan.

“But I’m a nurse, I use it to help people,” Isela told her agent. “If there is an overdose, I could save their life.”

That’s a message public health leaders aim to spread far and wide. “Be prepared. Get Naloxone. Save a life,” was the message at the top of a summaryÌý from the U.S. surgeon general in April.

But some life insurers consider the use of prescription drugs when reviewing policy applicants. And it can be difficult, some say,Ìýto tell the difference between someone who carries naloxone to save others and someone who carries naloxone because they are at risk for an overdose.

Primerica is the insurer Isela said turned her down. (NPR and KHN have agreed to use just Isela’s first name because she is worried about how this story might affect her ongoing effort to get life insurance.) The company said it can’t discuss individual cases. But in a prepared statement, Primerica noted that naloxone has become increasingly available over the counter.

“Now, if a life insurance applicant has a prescription for naloxone, we request more information about its intended use as part of our underwriting process,” saidÌý, the vice president for corporate communications. “Primerica is supportive of efforts to help turn the tide on the national opioid epidemic.”

After Primerica turned her down, Isela applied to a second life insurer and was again denied coverage. But the second company told her it might reconsider if she obtained a letter from her doctor explaining why she needs naloxone. So, Isela did contact her primary care physician — and then realized that her doctor had not prescribed the drug.

Isela bought naloxone at a pharmacy. To help reduce overdose deaths,ÌýÌýandÌýÌýhave established aÌýÌýfor naloxone — one prescription that works for everybody. Isela couldn’t just give her insurer that statewide prescription; she had to find the doctor who signed it. As it happens, that physician —ÌýÌý— also works at Boston Medical Center.

Walley is an associate professor of medicine at Boston University; he also works in addiction medicine at Boston Medical Center and is the medical director for the Opioid Overdose Prevention Pilot Program at the Massachusetts Department of Public Health.

“We want naloxone to be available to a wide group of people — people who have an opioid use disorder themselves, but also [those in] their social networks and other people in a position to rescue them,” Walley said.

He said he has written a half-dozen letters for other BMC employees denied life or disability insurance because of naloxone, and that troubles him.

“My biggest concern is that people will be discouraged by this from going to get a naloxone rescue kit at the pharmacy,” Walley said. “So this has been frustrating.”

The life insurance hassle — and threat of being turned down —Ìýhas discouraged Isela and some of her fellow nurses. She is not carrying a naloxone kit outside the hospital right now because she doesn’t want it to show up on her active medication list until the life insurance problem is sorted out.

“So if something were to happen on the street, I don’t have one — just because I didn’t want another conflict,” Isela said.

BMC has alerted the state’sÌý, which has said in a written response that it is reviewing the cases and drafting guidelines for “the reasonable use of drug history information in determining whether to issue a life insurance policy.”

But Isela isn’t a drug user. And yet, she is being penalized as if she were.

, who runs the Grayken Center for Addiction Medicine at BMC, said friends and family members of patients with an addiction must be able to carry naloxone without fear that doing so will send them to the insurance reject pile.

“It’s incumbent on all of us to make sure that we try to kind of nip this in the bud,” he said, “before it is any more wide-scale.”

Botticelli said increased access to naloxone across Massachusetts is one of the main reasons overdose deaths are down in the state. The most recent state report showedÌýÌýthrough the first nine months of 2018 compared with the same period in 2017.

Botticelli relayed his concerns in a letter to Dr. Jerome Adams, the U.S. surgeon general, who says he contacted the National Association of Insurance Commissioners. That group says it has not heard of any cases of life insurance applicants being denied because they purchased naloxone.

Adams said it’s good to — as Botticelli suggestsÌý— nip the problem in the bud.

“Naloxone saves lives,” Adams said, “and it is important that all Americans know about the vital role bystanders can play in preventing opioid overdose deaths when equipped with this lifesaving medication.”

Isela said the second company that rejected her has agreed to let her reapply, in light of Walley’s letter stating that she carries the drug so that she can reverse an overdose. Isela is in the process of reapplying.

This story is part of a partnership that includes , and Kaiser Health News.

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Eighty percent of the 148 underwriters who were surveyed by reinsurer Munich Re at the Association of Home Office Underwriters annual conference last year said their company factors marijuana use into its decisions on how to price policies and whether to offer coverage. Yet, of those, 29 percent classify marijuana users as nonsmokers, potentially allowing them to qualify for the best nonsmoker rates.

How often recreational users smoke pot is a key question for life insurers. At Prudential, for example, people can get high as often as three times a week and still qualify for nonsmoking rates. Someone who admits to smoking four to six times per week would have to pay a bit more, while anyone who uses marijuana daily wouldn’t be offered a policy, said Thomas Farrell, vice president of life underwriting at Prudential’s individual life insurance business.

At MetLife, anyone who smokes marijuana less than once a week is considered a nonsmoker, said Meghan Lantier, a spokeswoman for the company.

For life insurers, frequent pot smoking is a red flag in the same way that frequent alcohol consumption is, said Bill Moore, vice president of underwriting and medical at Munich Re, in an interview aboutÌý.

“The more you have, the higher the risk is because you’re more exposed to things that could cause death,” he said. “Do they smoke and drive, have they had infractions, are they flying an airplane while using marijuana? Those are all things a carrier would look at and price those risks.”

Medical marijuana use is generally a different calculus altogether for insurers, Moore said. People who smoke pot to reduce pain or nausea associated with cancer, arthritis or AIDS, for example, will be evaluated based on the underlying disease or condition.

This week, , along with the District of Columbia, to legalize medical marijuana.ÌýFour states and D.C. allow recreational use. Under federal law, however, marijuana remains a Schedule 1 drug, judged to have no medical value and a high potential for abuse.

In contrast to life insurers, health insurance companies don’t factor in marijuana use in rate-setting decisions, said Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group.

“The substance is still prohibited on the federal level, so health plans don’t have specific questions to prompt for marijuana use among enrollees,” she said.

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It is the first such offering to be publicly announced by a major American insurer, and it signals a growing recognition that HIV/AIDS has evolved from a death sentence into a chronic but manageable disease, HIV advocates and insurance agents said.

The coverage, in the form of convertible 10- or 15-year term life insurance policies, will be available to people who are HIV-positive but otherwise healthy, according to the insurer. Ìý term policies can be converted to permanent policies covering an entire life.

Life expectancies for HIV-positive people now are rising to the point that some American and Canadian patients diagnosed at a young age . But no cure exists for the disease, which requires access and adherence to medication. ÌýAnd the longer that HIV/AIDS patients live, the more they are , including cancer, osteoporosis, and heart, liver and kidney disease.

The life insurance industry routinely covers people with other chronic diseases, including cancer and Hepatitis C, although at a higher price than for healthy applicants. But HIV-positive people typically cannot buy individual life insurance policies, beyond minimal coverage, at any price, insurance agents said.

People with HIV/AIDS can’t legally be excluded from the “guaranteed issue” group life insurance policies offered by some employers, but those policies typically don’t pay out more than $50,000. A positive HIV test remains cause for automatic denial of higher-value individual term life insurance policies that require a medical review, agents said. That’s true even if the applicant has an undetectable viral load.

“We have not yet seen the terms of the life insurance product being offered … but it seems like a fantastic development for people living with HIV in need of term life insurance,” said Scott Schoettes, HIV Project National Director of LambdaÌýLegal, an organization that works to protect the rights of the LGBT and HIV/AIDS community.

“Finally, an insurance company has realized thatÌýthis is the right thing to do and that it isÌýprofitableÌýfrom a business perspectiveÌýto offer this product to people living with HIV.ÌýÌýNow that there is oneÌýcompany out there doing this, it will encourage others to do the same when they see that there is money to be madeÌýin this market,” Schoettes said.

In offering the new coverage, Prudential has partnered with ,Ìýa financial services startup serving HIV-positive people,Ìý which has researched medical underwriting, life expectancy and other data on HIV/AIDS and has been key to developing the product. The startup will provide information to consumers and insurance agents as well as manage the application process for Prudential.

In its research, ÆQUALIS co-founder Bill Grant said, the company used data from “viaticals” – insurance policies sold for their cash value by people after their HIV diagnosis – to plot new mortality curves. Many of those sold policies haven’t generated income for the buyers because the patients survived much longer than expected. That analysis was convincing to Prudential and to a German re-insurer that will accept some of the financial risk of insuring HIV-positive patients, Grant said.

“There’s been just enough history to project long enough into the future to get started on this path,” Grant said.

Grant said he started the company with business partner Andrew Terrell to address inequities in coverage and to help change the national conversation about HIV/AIDS. He and insurance agents noted that life insurance often is necessary not just to protect loved ones but also for certain business transactions or to adopt children. Grant said he only learned that his brother was HIV-positive when he was denied life insurance coverage that the two brothers needed to complete a business deal.

The surrounding actor Charlie Sheen’s recent disclosure that he is HIV-positive – emphasizing his long-kept “secret” — “is an incredible reminder that this stigma still exists,” he said.

Before now, some insurance companies have quietly experimented with underwriting policies for HIV-positive clients, but the criteria have been tough to meet. Potential buyers had to be on aggressive antiretroviral treatment since diagnosis, confirm that their viral loads were undetectable and meet certain CD4 lymphocyte (T cell) counts, in addition to meeting age and other health requirements, according to insurance agents who had sought the coverage.

Aaron Baldwin, Ìýa San Francisco insurance agent who is open about being HV-positive and specializes in financial planning for people with HIV, Ìýsaid that he provided health and financial information on 20 HIV-positive prospects in good health to one such company, Lincoln Financial Group. All were rejected, he said.

Ed Hinerman, an independent insurance agent in Nathrop, Colorado, said he also sent Lincoln a HIV-positive client whom he believed met the company’s stringent criteria. “The denial came within hours,” Hinerman said.

Asked to comment, a Lincoln Financial Group spokesman said he could not speak to the agents’ experiences and added that the company did not currently have a specific underwriting program for HIV-positive people.

Baldwin acknowledged, however, that medical underwriting is complex, and data are lacking on the long-term effects of HIV/AIDS drugs. Underwriters may not understand the subtleties of HIV/AIDS treatment research, he said.

For example, a patient may temporarily stop HIV/AIDS medications to participate in a study on “structured treatment breaks” to reduce side effects, Baldwin said. An underwriter might see that as noncompliance. Or an underwriter might note an applicant taking an HIV medication and not understand that it’s for prevention, not treatment, Baldwin said.

“For an underwriter, it’s probably a hot mess,” Baldwin said.

Baldwin said the Prudential/ÆQUALIS initiative “represents new hope” for his clients – and himself.

He is particularly looking forward to obtaining a life insurance policy for one of his clients, a young HIV-positive man whose parents had co-signed on a new round of loans for his medical school education, unaware of his diagnosis. The young man wanted to buy a life insurance policy to protect his parents from that debt if he died.

“The new offerings will continue to open doors and allow HIV-positive people to protect their loved ones, their families and their businesses,” Baldwin said.

Ìý

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