63 HIV organizations urge Biden administration to require insurers to cover long-acting PrEP without cost-sharing

New Drugs Improve Adherence & Will Dramatically Decrease New HIV Infections

Washington DC… Today, a coalition of 63 organizations dedicated to ending HIV has called upon the Biden administration to issue updated guidance to insurers to ensure compliance with the latest United States Preventive Services Task Force (USPSTF) recommendation for HIV Pre-Exposure Prophylaxis (PrEP), which includes long-acting regimens.

In a letter addressed to Chiquita Brooks-LaSure, Administrator of the Centers for Medicaid and Medicare Services (CMS), the groups highlight the urgency of ensuring broad and equitable access to PrEP free of insurance barriers. The USPSTF’s most recent A-grade recommendation, finalized on August 22, 2023, includes new medications such as the first long-acting PrEP drug, which offers superior efficacy in preventing HIV compared to daily oral PrEP. New commercial insurance plans issued after August of this year, which is just a few weeks away, must align with the recommendation.

The letter requests that CMS issue new guidance that requires insurers to cover all forms of PrEP to ensure PrEP users have a choice of options and can access the drug that best meets their individual needs. In the updated guidance the groups want CMS to ensure that insurers can’t satisfy their ACA requirements by just covering one drug, but all current and future FDA-approved PrEP drugs, just as CMS requires for contraception.  Additionally, since prior authorization is creating significant barriers to PrEP access and furthering racial and ethnic inequity, the groups are asking CMS to prohibit insurers from employing prior authorization.  Several states, including New York and California, already prohibit prior authorization for PrEP.

“Long-acting PrEP can be the answer to low PrEP uptake, particularly in the communities not using PrEP today. The Biden administration has an opportunity to ensure that people with private insurance can access PrEP now and into the future, free of any cost-sharing, with properly worded guidance to insurers,” commented Carl Schmid, Executive Director of the HIV+Hepatitis Policy Institute.

He continued, “Poor PrEP uptake among various racial and ethnic groups is an example of failed healthcare decisions of the past. CMS can help correct these inequities by requiring insurers nationwide to cover all FDA-approved PrEP drugs, without burdensome prior authorizations, and begin the vigorous enforcement of ACA protections that has been lacking to date.”

Current statistics reveal significant disparities in PrEP uptake: only 36 percent of those who could benefit from PrEP are using it. Black individuals constitute 39 percent of new HIV diagnoses but only 14 percent of PrEP users, while Hispanic individuals represent 31 percent of new diagnoses but only 18 percent of PrEP users. By contrast, Whites represent 24 percent of HIV diagnoses but 64 percent of PrEP users.

According to modeling conducted for HIV+Hep, which was based on the clinical trials of a once every 2-month injection, 87 percent more HIV cases would be averted compared to daily oral PrEP, with $4.25 billion in averted healthcare costs over 10 years.  New long-acting regimens that are in the pipeline most likely will yield even more positive results. Just last month, a clinical trial resulted in zero infections among cisgender women of a twice a year injection.

That same modeling estimates that 73 percent of current PrEP users and 55 percent of the estimated 1.2 million people who can benefit from PrEP have commercial insurance.

Despite the first PrEP guidance to insurers in July 2021, PrEP users continue to report that insurers are burdening them with prior authorizations and repeatedly charging cost-sharing for both the drug and ancillary services, including office visits and required laboratory testing. One recent review of claims data found that 36 percent of PrEP users were charged for their drugs.  Even 31 percent of those using generic PrEP faced cost-sharing.  A CDC study concludes that one-third of commercially insured PrEP users were charged cost-sharing for PrEP ancillary services.

In addition to the community sign-on letter organized by the HIV+Hepatitis Policy Institute, HIV+Hep sent a letter to the Biden administration on July 2^nd which describes the need and reasoning for an updated guidance in much more detail.

Additional signatories to the community letter include: Advocates for Youth, AIDS United, Equality California, Fenway Health, Human Rights Campaign, International Association of Providers of AIDS Care, Latino Commission on AIDS, Latinos Salud, National Coalition of STD Directors, National Health Law Program, NASTAD, NMAC, The AIDS Institute, Treatment Action Group, and Whitman-Walker Health.

# # #

The HIV+Hepatitis Policy Institute is a national, non-profit organization whose mission is to promote quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.