Answered by:
Stuart D. Federman, PharmD, AAHIVP
Gateway Apothecary
Saint Louis, MO


There has been a lot of talk about insurance companies only covering individual HIV products instead of covering a single tablet regimen. While this is a less than ideal situation for patients, the insurance industry has been using this strategy in many states, including my home state of Missouri. This has now become our reality.

Experienced patients who have been on medication for six months or more have been required to get a prior authorization to obtain approval for a single tablet regimen. The plans in Missouri have a grandfather clause where if a patient has been taking a single tablet regimen he or she is able to continue the medication as long as he or she can prove adherence.

The patients who have not been on the single tablet for six months or do not have specific reasons on why they cannot take the individual components of the regimen are stuck having to split the regimen into multiple tablets per day. Other plans have not included new medications on their plan like Tivicay or Triumeq because the medication was not available when the plan was created. These medications have been even trickier to achieve approval for since the requirements for approval are difficult to obtain.

Patients who had to split their single tablet regimen and were having difficulty taking the multiple pills per day had to at least take the medication for a month. If after a month the patient was still having a difficult time with the medications, we were then able to provide a written prior authorization stating that the patient had tried and failed to be able to get the approval for the single tablet regimen.

The state of Illinois for years through their Medicaid program has not allowed patients to get any Truvada based regimens as a single tablet, due to the fact that they were able to make a deal with Gilead for a substantial discount for Truvada. They have also made it very difficult to get patients to get Complera or Stribild, but Gilead has stepped in and allowed Illinois Medicaid patients to get a quick approval on their patient assistance program.

This may get tougher in 2015 when Sustiva, a component of Atripla, patent expires and insurance companies looking to save costs may require patients to use the generic Sustiva with Truvada. This is definitely an issue for providers; medicine is practiced as an evidence based science and to have to base decisions on cost is not the best way to provide care to patients.

The best thing that I can recommend for patients is to be advocates for themselves with insurance companies; if you are not able to advocate for yourself please find a pharmacist or provider who is willing to help. Most insurance companies will bend if you create enough headaches for them. You may need to make multiple phone calls or talk to different people at the insurance company to get what you want.

Please feel comfortable talking with your physician or pharmacist about any insurance problems that you are experiencing. Providers are not able to read your mind; please verbalize issues that you are experiencing, usually if you are having a problem we have another patient who has had the same problem and we may already have a solution to your issue.

Additional writing by Mason Stewart, student pharmacist at the St. Louis College of Pharmacy.