The new year kicks off with some encouraging HIV prevention news: Most health insurance plans will be required to cover pre-exposure prophylaxis (PrEP) without charging clients anything out of pocket in the form of co-payments or deductibles.
“All insurers failing to offer PrEP without cost sharing beginning in January 2021 are clearly not following the law,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, in a compliance review of 2021 health plans.
PrEP coverage will be required by law because in June 2019 the U.S. Preventive Services Task Force, an independent panel of health experts, gave PrEP a grade A recommendation, meaning that scientific evidence shows that PrEP works very well and is safe. The Affordable Care Act requires health plans to cover preventive services that receive an A or B grade. After the task force’s recommendation, health insurers were given time to adjust to the new ruling, but the grace period ends in January. Many have already begun covering PrEP and its related doctor visits and lab work.
Unfortunately, this doesn’t mean all insurers will automatically comply or that they’ll do so in a manner that’s easy for the public to understand. As the Los Angeles Times reports, different health plans place drugs in varying tiers, and it may be difficult to figure out which drugs are covered and whether they require preauthorization. What’s more, PrEP requires doctor visits and lab work—for example, to test for sexually transmitted infections and kidney health. These services are recommended every three months for PrEP users, but the task force recommendation didn’t specify that they must be covered without cost to clients. Advocates are pressuring the federal government to clarify the matter, and New York and California have already issued guidance or requirements that the services be covered.
If a health plan does charge for the services or medication, people “have to appeal to the insurance company and then to the state if they don’t succeed,” Nadeem Israel of AIDS Foundation of Chicago told the LA Times, adding that “most people don’t know to do that.”
In the United States, PrEP is available as the daily tablets Truvada and Descovy; both are manufactured by Gilead Sciences and consist of two meds. A generic version of Truvada became available this past fall. To learn more, see “What’s the Difference Between Truvada and Descovy for PrEP?” and “Prevention: Generic Truvada.” For more general information, see the POZ Basics on HIV Prevention.
It’s no surprise that the expert panel gave PrEP a grade A recommendation. Scientists estimate PrEP to be about 99% effective among men who have sex with men and to be greater than the current estimate of 88% to 90% effectiveness for heterosexual men and women. For more details, see the POZ article “How Well Do U=U and PrEP Work? The CDC Updates Its Answers.” For more details about the grade A recommendation and which groups are recommended to take PrEP, see our reporting from last June, “Great News! Expert Panel Recommends PrEP for HIV Prevention.”
In related news, don’t be fooled by social media posts claiming PrEP is dangerous. They’re posted by personal injury lawyers and have been deemed misleading and false. For more, see “They’re Still Here! Scary HIV Ads on Facebook Won’t Go Away.”