Tuesday, March 28, 2023

Government Orders That PrEP Must Be Free Under Most Insurance Plans

The federal government recently announced that almost all health insurers must cover PrEP, or pre-exposure prophylaxis, with no cost sharing, including for the drug itself and  clinic visits and lab tests.

The bottom line is that a prescription of Truvada or Descovy, the two approved forms of PrEP, should now be totally free for almost all insured individuals. A prescribing physician, however, must demonstrate to the insurer that Descovy in particular is medically necessary for any specific patient to qualify for zero cost sharing for that drug’s use as HIV prevention.

The guidance that the Centers for Medicare and Medicaid Services, along with the Department of Labor and the Department of the Treasury, sent to health insurers on July 19 requires that insurers must comply within 60 days. The rule says insurers must not charge copays, coinsurance or deductible payments for the quarterly clinic visits and lab tests required to maintain a PrEP prescription.

Insurers were already required to stop charging out-of-pocket fees for the medication by January 1, 2021.

These additional requirements, which will lift what has likely been a substantial barrier to PrEP access for individuals with low income in particular, are the result of the U.S. Preventive Services Task Force granting this form of HIV prevention an “A” rating in 2019. Under the Affordable Care Act, such a rating for preventive health care services, including tests for various diseases such as HIV itself, means they must be covered by almost all insurers at no cost to the insured patient.

Truvada was approved for use as HIV prevention in 2012. When taken daily, the tablet reduces men’s risk of contracting the virus from sex with other men by more than 99 percent. PrEP reduces women’s risk of HIV by at least 90 percent.

Descovy, which is associated with improvements in bone density and kidney function tests compared with Truvada, was given the green light by the Food and Drug Administration in 2019.

Both drugs are manufactured by Gilead Sciences, the primary provider of HIV treatments. Since this spring, Truvada has been available in a generic form with a list price as low as $30 per month. By comparison, Descovy’s list price is currently $1,930 and Truvada’s is $1,842.

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