The HIV + Hepatitis Policy Institute is urging HHS to require insurers count copay assistance towards patients’ out-of-pocket maximums before President-elect Donald Trump takes office in January, after CMS in its October Notice of Benefit and Payment Parameters (NBPP) proposed rule for 2026 did not address copay accumulators but promised to in future rulemaking.
The HIV+Hepatitis Policy Institute filed formal complaints with insurance regulators in five states against Medica and Harvard Pilgrim, which cover a combined 4.2 million people, alleging that the insurers discriminate against people living with HIV.
Carl Schmid says that limiting access to direct-acting antivirals “should have never happened” and noted advocacy groups and experts have called for wider access since Solvadi and Harvoni were approved a decade ago. He claims states are breaking federal laws when instituting prior authorization and other restrictions and points to a 2020 study that found class-action lawsuits brought by Medicaid beneficiaries in Colorado, Michigan, Missouri, Washington, and other states “have helped end DAA rationing based on disease severity.”
The HIV+Hepatitis Policy Institute noted the previous Trump administration’s history with the HIV community. “In his 2019 State of the Union address, Trump announced that we would ‘eliminate the HIV epidemic in the United States within 10 years.’ This led to the historic Ending the HIV Epidemic [EHE] initiative that increases HIV testing, treatment and prevention programs, including scaling up PrEP [pre-exposure prophylaxis], which are drugs that prevent HIV. At the same time, his administration proposed cuts to other HIV and health programs and proposed to dismantle the Affordable Care Act, including its nondiscrimination protections,” wrote Carl Schmid, executive director of HIV+Hep, who also noted: “In recent years, House Republicans have proposed to eliminate funding for the [EHE] program.”
As for the roughly 45,000 people who currently get their PrEP through Medicare, to maintain access to care, they will need to contact their pharmacy to make sure the pharmacy can bill for Part B drugs. That’s according to HIV services coverage expert Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. Schmid says that certain large pharmacy chains like CVS and Walgreens are already in that network. If the pharmacy can’t bill for Part B drugs, Schmid recommends that people talk to their health care provider about finding a pharmacy that can. And he says that if an Advantage plan refuses to fully cover PrEP and its related services despite the government ruling, one should call the plan to tell them of the ruling—or contact Medicare directly at 1-800-MEDICARE or submit a complaint online.