The federal government reminded health insurers that they must cover pre-exposure prophylaxis (PrEP) to prevent HIV and that they must do so at no cost to clients. The federal guidance clarified that insurance plans must also cover the health services related to PrEP, such as doctor visits, blood work and tests for HIV and sexually transmitted infections (STIs).
The guidance was posted July 19 as a document addressing frequently asked questions titled “FAQs About Affordable Care Act Implementation Part 47.” Health plans have 60 days to comply with the PrEP coverage.
“We are pleased that the federal government has issued this long-awaited guidance to insurers that will reduce barriers to PrEP and help prevent further HIV infections while advancing efforts to end HIV in the United States,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, in a press statement. “Now we must ensure all are fully complying with their legal requirements, including those spelled out in the new guidance, and federal and state regulators enforce them.”
@HIVHep’s Carl Schmid lauded the federal govt issuing guidance that “associated services with #PrEP, such as provider visits & #HIV, #hepatitis, & STD testing along with other laboratory tests must be covered with no #patient cost-sharing”: https://t.co/9r4RVzmlvw. pic.twitter.com/pt8VRa01KG— HIV+Hepatitis Policy Institute (@HIVHep) July 21, 2021
This isn’t the first federal guidance regarding PrEP coverage. As POZ reported in December 2020, insurers have been required to cover PrEP since January 2021. That’s 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 (ACA, or Obamacare) requires health plans to cover preventive services that receive an A or B grade. After the task force’s recommendation, health insurers were given until January 2021 to adjust to the new ruling.
Although this sounds straightforward, it gets complicated because health plans place drugs on different tiers (with the cost to clients increasing with each tier) and prescriptions often require preauthorization (a determination by the health plan that the medication is necessary), which can be difficult for people to figure out. What’s more, it’s recommended that people on PrEP visit their health care provider every three months and have lab work and tests for HIV and STIs. However, the additional cost of these services wasn’t addressed by the U.S. Preventive Services Task Force, which meant that if health insurers didn’t cover them, people had to appeal to the company and the state—another potential barrier to access. Advocates pressured the federal government to clarify what, exactly, must be covered. The result is this week’s FAQ guidance.
As history shows, not all health plans follow the law. In November, the HIV+Hep Policy Institute reviewed 2021 health plans and found that many failed to cover PrEP and related costs, meaning that they weren’t complying with federal law.
This month, the institute followed up on updated health plans and found that several still failed to meet ACA rules in numerous ways. A press release rounds up the plans and violations:
- In Connecticut, ConnectiCare places the two brand-name PrEP drugs (Truvada and Descovy) on Tier 4, and none on its preventive rug Tier 0. It also notes that there is a generic Truvada.
- In Ohio, MedMutual places the two brand-name PrEP drugs along with generic Truvada on Tier 4, and none on its preventive drug Tier 5.
- In Georgia, Kaiser Permanente places one brand-name PrEP drug on Tier 5 and generic PrEP on Tier 2. None are on its preventive drug Tier ACA.
- In Washington state, Kaiser Permanente places generic Truvada on the preferred generic Tier 1 and the two brand-name PrEP drugs on Tier 4, rather than on its preventive drug Tier P. However, the insurer has a separate document that lists preventive drugs with zero patient cost-sharing, and it includes PrEP.
- In Washington, DC, Maryland and Virginia, Kaiser Permanente places Descovy on Tier 2 and generic Truvada on Tier 1 and Tier 3. In neither instance does it indicate the drug has zero cost-sharing, which should be denoted by a “PRV,” for preventive. A separate document lists preventive drugs, including PrEP.
It’s no surprise that the expert panel gave PrEP a grade A recommendation in 2019. 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.”
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 last fall. To learn more, see “What’s the Difference Between Truvada and Descovy for PrEP?” and “Cheaper Generic PrEP Now Available in the United States.” For more general information, see the POZ Basics on HIV Prevention.
In related PrEP news, the availability of lower-cost generics might actually be bad news for HIV prevention efforts because of a federal drug pricing law called 340B. For background, see “Generic PrEP Highlight How Even Low-Cost HIV Care Relies on High Drug Prices” and “PrEP Programs Face Devastating Loss of Funding for HIV Prevention.”
Did you know that a national program has been set up to deliver HIV prevention via mail at no cost? To learn more, read “‘Ready, Set, PrEP’ Offers HIV Prevention Meds by Mail.”