Yesterday, July 19, 2021, the federal government issued guidance to insurers reminding them of their obligation to cover pre-exposure prophylaxis (PrEP) at no cost to their beneficiaries. It has long been clear to insurance companies that this requirement went into effect on January 1, 2021.
Late last year, when the HIV+Hepatitis Policy Institute conducted spot checks of 2021 insurance plans, it found that many were not in compliance with this legal requirement. During follow up reviews, they found many plans had been updated to offer at least one PrEP drug without cost-sharing, while others were still in violation.
Under the recommendation issued, all non-grandfathered private health plans – including individual, small group, large group, and self-insured plans – must cover PrEP without cost-sharing (such as a copay or coinsurance) beginning no later than the 2021 plan year.
The FAQ guidance released yesterday clarifies that associated services with a PrEP prescription must also be covered with no patient cost-sharing. This includes provider visits and HIV, hepatitis, and STD testing along with other laboratory tests. The announcement also states the federal government said insurance plans will have 60 days to be in compliance with the coverage of PrEP support services.
RICH PEDRONCELLI/AP
There are currently two PrEP medications approved for daily use, Truvada (brand/generic) and Descovy. The guidance only requires that one be covered with no cost sharing meaning insurers can impose cost sharing on an equivalent branded version. However, issuers must cover the equivalent branded version if deemed medically necessary by the prescribing physician.
If your insurance provider is not complying with this new guidance from the federal government, you can contact them and include the official guidance. They have 60 days from July 19, 2021 to comply.
FAQs About Affordable Care Act Implementation – Part 47
Other sources:
HIV+HEP Policy Institute: Federal Government Issues Guidance to Insurers on Coverage of HIV Prevention Drugs
HIV Plus Magazine: U.S. Insurance Companies Must Now Cover PrEP With No Cost-Sharing
NBC News: PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans
Fierce Healthcare: Feds call on insurers to fully cover HIV prevention drug PrEP without cost-sharing