The nonprofit patient advocacy group HIV + Hepatitis Policy Institute said they are pleased with the rule, as they continue to receive complaints surrounding coverage of pre-exposure prophylaxis, or PrEP, a drug regimen taken to prevent HIV. The group says some health plans are denying claims or still requiring cost sharing for certain codes.
“With low uptake of PrEP among the communities most impacted by HIV, this insurance coverage requirement with zero cost-sharing will help jumpstart the use of more effective forms of PrEP and lead to fewer HIV transmissions,” Carl Schmid, a gay man who is executive director of the Washington, D.C.-based HIV+Hepatitis Policy Institute, stated about the Biden administration’s announcement.
Carl Schmid, executive director of the HIV+ Hepatitis Policy Institute, said in a statement before the new guidance, some insurers may have only covered daily oral PrEP. “With low uptake of PrEP among the communities most impacted by HIV, this insurance coverage requirement with zero cost-sharing will help jumpstart the use of more effective forms of PrEP and lead to fewer HIV transmissions,” Schmid said Monday (Oct. 21). “The updated USPSTF recommendation is not drug-specific, but rather for PrEP in general to prevent HIV which includes ‘effective antiretroviral therapy.’ This will be important as new longer acting PrEP drugs become available.”
The news comes after CMS released guidance switching PrEP from Medicare Part D to Part B, allowing all forms of the medication to be covered without cost-sharing. The HIV+Hepatitis Policy Institute, along with over 60 other advocates, had called on the administration to issue updated guidance to insurers to ensure coverage of all FDA-approved PrEP medications for HIV, including long-acting regimens.
Recent research by the HIV+Hepatitis Policy Institute has revealed that over 150 employers and insurers are taking advantage of the EHB loophole. This list includes: major companies such as Chevron, Citibank, Home Depot, Target, and United Airlines; universities including Harvard, Yale, and New York University; unions like the New York Teamsters and the Screen Actors Guild; states such as Connecticut and Delaware; and insurers, including several Blue Cross/Blue Shield plans. Patient advocacy groups have reacted strongly to these omissions. Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, stated, “Every day these rules are delayed is another day that insurers and PBMs are pocketing billions of dollars meant for patients who are struggling to afford their drugs.” This sentiment reflects the frustration of many who have long advocated for stronger protections.