HIV Prophylactic PrEP Must Be Free On Most Insurance Plans

NS guidancePublished by the Medicare Medicaid Service Center with the Ministry of Labor and the Ministry of Finance, was sent to a health insurance company in mid-July. The insurer states that it must not claim out-of-pocket, joint insurance, or deductible payments for clinic visits and laboratory tests that patients must receive to maintain their PrEP prescription.

As of January 1, 2021, insurers had to fully cover the drug itself, thanks to the “A” rating granted by the US Preventive Health Commission in 2019. In affordable care methods, an “A” rating is a preventative treatment that should be fully covered by the insurer free of charge to the patient.

Now, the new guidance means that most US insureds will have access to PrEP — When All Related Services — Completely Free.

Insurers have a 60-day grace period to comply with the latest rules.

PrEP is a daily pill that reduces the risk of getting HIV from sex by 99% when taken as prescribed. Centers for Disease Control and Prevention (CDC).. The use of injectables reduces the risk of getting HIV by at least 74%.

Doctors said PrEP could be prescribed to patients for a variety of reasons Dr. Antonio Urbina, Professor of Medicine at Mount Sinai School of Medicine and Medical Director of the Clinical Education Initiative at the AIDS Institute, New York State Department of Health.

The drug is indicated for people who have a sexual partner with HIV or who have sex with people at risk of becoming infected with HIV without barriers.

“Anyone diagnosed with a sexually transmitted disease may have signs of starting pre-exposure prophylaxis,” Urbina said.

PrEP is also recommended for people using injectables that share equipment such as needles and syringes.

Still, despite its effectiveness in reducing the risk of HIV, PrEP has not reached many Americans who can benefit from it. 2018 analysis According to the CDC, about 1.1 million adults in the United States are at risk for HIV and need to provide PrEP, but in the year the study was conducted, 78,360 PrEP prescriptions were prescribed at commercial pharmacies. It was only.

“where [PrEP use] The biggest scale-ups are white gay men, “says Urbina. “But, Big gap.. The majority of new HIV infections are found in gay men, but are more common in brown and black gay men. “

“Similarly, in cisgender women, the majority of new infections are in black and brown women,” he continued. “also, Transgender community, And all these community uptakes are disproportionately lower than white gays. [cisgender] male. “

When it comes to dealing with the gap between recipients of PrEP, there are various barriers, from lack of awareness about the drug to the stigma, but cost plays a major role.

The average monthly supply cost of Truvada or Descovy is about $ 2,000. A generic version of Truvada is also available for around $ 40 per month.

However, the biggest impact on a particular insured is the cost of related services required to maintain a PrEP prescription.

“PrEP is not a drug that receives a prescription in 11 supplements for a month after seeing a doctor,” Urbina explains. “Patients should be seen every 3-4 months.”

At the time of these appointments, patients may have to undergo kidney and liver tests, as well as hepatitis, STI, and HIV tests.

“These lab tests and office visits add up to hundreds of dollars,” Schmid said.

Currently, individuals with high-deductible health insurance plans may be charged these costs, perhaps several times before the insurance begins. Highly out-of-pocket patients can also face high billing.

“So you can see how it can be out of reach for many, depending on the type of insurance plan they have,” Schmidt said. “now, [with the new mandate] You don’t have to worry about it. “

While the new guidance is widely admired as a major milestone in HIV prevention, one issue to address is compliance from insurers.

After an “A” rating by the US Preventive Health Commission, the HIV + Hepatology Policy Institute conducted a spot check of 2021 plans on federal and state exchanges, many covering federal and state costs. I found that I did not comply with the legal requirements to do so. Drug PrEP without cost sharing.

As a result of recent reviews, the organization has renewed its offering to cover at least one PrEP drug at no cost to patients, while some violations are still occurring. I found that.

But for Schmidt and other HIV supporters, this is a concern for progress.

“Insurers seem to have responded to our previous analysis,” Schmidt said. Statement on the HIV + Hepatitis Policy Institute website.. “But now we need to make sure that everything is in full compliance with legal requirements, including those specified in the new guidance, which federal and state regulators are enforcing. . ”