Insurance must now cover the costs of PrEP

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The Biden administration is asking insurance companies to offer PrEP without copayments or deductibles.

PrEP, or pre-exposure prophylaxis, refers to two antiviral drugs – under the brand names of Truvada, which was approved by the Federal Food and Drug Administration in 2012 and Descovy, which was approved in 2019 – that are taken by people who are HIV negative. people to prevent HIV infection.

According to guidelines released July 19 jointly by the U.S. Departments of Labor, Health, and Human Services, and the Treasury, the Patient Protection and Affordable Care Act requires insurance companies to provide services based on evidence with an “A” or “B” rating from the US Preventive Services Task Force with no cost sharing requirement in most situations.

As PrEP received an “A” rating from the working group in 2019 as “effective antiretroviral therapy for people at high risk of acquiring human immunodeficiency virus (HIV),” according to the guidelines, the companies no longer need to charge a co-payer or deductible for the drug itself, laboratories and associated office visits.

The Bay Area Reporter reported at the time that this “A” rating would lead to an access mandate “which is expected to be fully implemented in 2021.”

Businesses will have 60 days to come into compliance, according to the guidelines, and state governments are encouraged to help with enforcement.

The cost of PrEP has created barriers to getting it to the communities that need it most. The Truvada brand typically sells for between $ 1,600 and $ 1,800 per month. A long-awaited generic version of Truvada hit the market in late 2019. But the wholesale price for the new pill from Teva Pharmaceuticals was around $ 1,455 for a 30-day supply.

As BAR reported in 2019, California Insurance Commissioner Ricardo Lara, a gay man, warned insurers that under state guidelines, they cannot deny coverage to PrEP users.

A report from the state’s insurance department found that several companies had denied or limited coverage, restricted the products available through expedited underwriting, imposed terms of coverage, or charged higher rates to PrEP users, although the names of the companies in particular were not disclosed by the state. .

A law that came into effect in California last year, drafted by gay state senator Scott Wiener (D-San Francisco) and then-gay congressman Todd Gloria (D-San Diego) allows Californians to get a two-month supply of PrEP from a local pharmacy without a prescription. The law also prohibits insurance companies from requiring patients to obtain prior authorization before using their insurance benefits to obtain PrEP or PEP from a pharmacy. (PEP refers to post-exposure prophylaxis and is a different drug.)

Wiener, who uses PrEP himself, told BAR that the new guidelines are “a big problem for HIV prevention.”

“PrEP has the potential to end new HIV infections, but only if we dramatically increase access,” Wiener said. “Eliminating cost-sharing for PrEP will be of great help in this effort.”

The HIV + Hepatitis Policy Institute, a nonprofit that advocates for people living with or at risk of contracting HIV and hepatitis, among other health issues, released a statement in support.

“We are delighted that the federal government has released these long-awaited guidelines 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 institute. “It appears that insurers have responded to our previous analysis. However, we now need to ensure that all are in full compliance with their legal requirements, including those set out in the new guidelines, and that federal and state regulators enforce them.”

Schmid called on both insurance companies and regulators to “do more to ensure that people with private insurance can get PrEP without cost sharing.”

“In addition, transparency in how insurers display coverage for preventative drugs such as PrEP requires special attention,” Schmid added. “We look forward to further reviews of the plan and to holding all parties accountable for providing clear and transparent information so that insured people who need PrEP can access it as easily as possible. “

The San Francisco AIDS Foundation and the Los Angeles LGBT Center did not immediately respond to requests for comment.

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