Amid PrEP Push, Some Plans Still Denying Coverage

In an attempt to decrease transmission of human immunodeficiency virus (HIV) and end the HIV epidemic, major stakeholders are taking steps to increase availability of pre-exposure prophylaxis (PrEP), according to a recent In Focus Blog post from the American Journal of Managed Care.  

Some managed care plans are introducing unnecessary roadblocks for beneficiaries, however, by denying coverage for Truvada (emtricitabine/tenofovir disoproxil fumarate) for PrEP.

“We still get plans saying, ‘Well, this medication is used for treatment,’ and therefore they won’t necessarily give coverage,” said Michael Kharfen, senior deputy director, HIV/AIDS, Hepatitis, STD, and TB Administration, Washington, DC, health department.

In actuality, the drug holds US Food and Drug Administration indications for both treatment and prevention of HIV, the blog explained.

“Managed care plans should see the benefit associated with this,” Kharfen added. “When we’re talking about lifetime HIV treatment costs [between] $375,000 and $400,000, PrEP is much more affordable than that, so there’s a financial incentive to cover PrEP.”

PrEP costs $1600 per month, according to the blog. To increase access for users with little or no insurance, Truvada maker Gilead recently extended eligibility for its medication assistance program from 6 months to 12 months. Starting in September, the drugmaker will boost its annual Truvada benefit from $4800 to $7200.

“At Gilead, we are committed to ensuring that people at risk of HIV have access to Truvada for PrEP tablets,” a Gilead spokesperson told the blog. “We support comprehensive payer coverage and maintain the Gilead Advancing Access program for qualified underinsured and uninsured people in the United States who cannot afford their medications.”

More and more state health departments are also introducing PrEP medication assistance programs, funded by state budgets, to expand access. The Washington, DC, health department, for instance, has spent nearly $1 million over the past 3 years on PrEP, according to the report. Residents without insurance coverage for the treatment can receive free Truvada starter packs the day they request them.

“This is truly the first medical intervention we’ve had to prevent HIV in the entire history of the epidemic,” said Mr Kharfen. “We’ve had other tools to prevent HIV acquisition or transmission, such as condoms or clean needles for those using drugs, but we’ve never had an opportunity like this.”

—Jolynn Tumolo