Many insurers failing to offer HIV prevention drug for free
November 17, 2020
Review of 2021 Plans Shows Compliance Varies by State and Insurer
Washington DC… In a review of health insurance plans being offered on federal and state exchanges in 2021, the HIV+Hepatitis Policy Institute is finding that many plans will not be in compliance with the legal requirement to offer pre-exposure prophylaxis (PrEP) to prevent HIV without patient cost-sharing.
Beginning in January 2021, most health plans must provide PrEP without cost-sharing based on the U.S Preventive Services Task Force “Grade A” recommendation of June 2019. Under the Affordable Care Act (ACA), insurers must offer USPSTF recommended services without cost-sharing in the plan year that begins one year after the date of the recommendation.
“All insurers failing to offer PrEP without cost-sharing beginning in January 2021 are clearly not following the law,” commented Carl Schmid, executive director of HIV+Hepatitis Policy Institute. “They have had plenty of time to prepare for this, and now people at risk of HIV who want to take PrEP and prevent HIV will face continued financial barriers to accessing it. This is completely unacceptable. State insurance regulators and the federal government, who should have been reviewing the plans, must immediately step in to ensure there is compliance with the law.”
As described below, the initial review of select plans also reveals how difficult it is for consumers to find preventive drugs on plan formularies and the lack of consistency among issuers.
HIV+Hep’s 2021 plan review has found:
- Kaiser Permanente’s plans in Colorado, Georgia, and Washington state place the two brand name PrEP drugs (Truvada and Descovy) on Tiers 4 and 5, and in Washington, DC on Tiers 2 and 3.
- Ambetter and CareSource in Georgia both place the two brand PrEP drugs on Tier 2.
- In Connecticut, ConnectCare places the two brand name PrEP drugs on Tier 4.
- In Ohio, Ambetter puts PrEP on Tier 2, CareSource on Tier 2, MedMutual on Tier 4, while Anthem and Molina in the state offer PrEP without cost-sharing.
- In Florida and Texas, Ambetter places two PrEP drugs on Tier 2.
- In California, Oscar is violating state insurance commissioner guidance that requires zero cost-sharing for all FDA approved drugs used for PrEP. Additionally, by instituting step therapy and prior authorization for Truvada, it is violating a state law that prohibits these practices for PrEP.
- BrightHealth, which has plans in 10 states, according to its formularies, offers PrEP on Tiers 3 and 5, depending on the state, and in many, requires prior authorization. However, BrightHealth also has a separate document of preventive services buried on its website that includes PrEP as a zero-cost preventive drug.
Some insurers are in compliance with the federal ACA requirement. In New Jersey, AmericaHealth, Horizon, and Oscar all offer at least one PrEP drug without cost-sharing. In Florida, the same is true for AvMed, Florida Blue, and Molina. Anthem, which is operating in 12 states, keeps Truvada on Tier 4, but after an additional click on the website the consumer learns that there is no cost-sharing, although it does require prior authorization.
Paying for PrEP usually first entails that the beneficiary meet a deductible, which could be several thousands of dollars. Additional cost-sharing, sometimes in the form of co-insurance, must be paid until the maximum out-of-pocket limit is reached. High patient cost-sharing has been a barrier to PrEP access and is expected to disappear in January 2021.
Over a year ago, members of the HIV community wrote to all state insurance commissioners and the Center for Consumer Information and Insurance Oversight (CCIIO) at Centers for Medicare & Medicaid Services (CMS) to urge them to take steps to ensure insurer compliance with the requirements for PrEP. New York’s insurance regulator acted by requiring compliance one year earlier, in 2020, and recently issued an order that all ancillary services, such as office visits and lab tests associated with PreP usage, be covered without cost-sharing. California’s insurance commissioner issued guidance that requires plans to cover all PrEP drugs without prior authorization, along with ancillary services without cost-sharing.
PrEP requires a prescription from a provider, periodic lab tests, along with HIV and hepatitis testing that must be included at no cost to the patient. The Trump administration recently issued an Interim Final Rule that clarifies insurers must cover associated services with no cost-sharing for USPSTF recommended preventive services. The plan review conducted by HIV+Hep was not able to determine coverage of these other services. All forms of PrEP will not work for everyone and people need access to the one that their provider prescribes; no matter the drug, it should be available without cost-sharing.
Federal guidance to issuers from CCIIO is particularly needed since they maintain the list of preventive services (which currently does not include PrEP) and to ensure that these ancillary services are included. Non-grandfathered health plans issued in June 2020 and after already had to be in compliance with the new PrEP requirements.
HIV+Hep realizes that the requirements for exchange plans do not begin until January 1, 2021; but these plans are being marketed now for 2021 and people shopping for health coverage should be provided with the correct information. HIV+Hep is issuing this report in order for issuers to take corrective action, to urge regulators to enforce the law, and to alert people who are on PrEP or thinking about taking PrEP as they select their health coverage. If plans are not in compliance, enforcement actions must be taken.
Some insurers clearly delineate preventive drugs with no cost-sharing on a separate tier, but that tier can be labeled as Tier 1, Tier 7, “Prev,” or just “ACA.” Others place PrEP on a high drug tier but then indicate it has $0 cost-sharing next to it. United Healthcare in Washington, DC places the only PrEP drug they offer on Tier 4, but if you click on the words “Tier 4” the consumer finds that it has zero cost-sharing. The transparency rule recently released by the Trump administration acknowledged this issue and requires issuers to better display in their plan documents that certain preventive services have no cost-sharing.
Access to PrEP is a key element in the country’s efforts to reduce the number of new HIV infections and eventually end HIV in the United States. There are initiatives to provide PrEP for free to people who are uninsured and educational outreach efforts to increase awareness of PrEP among people at risk of HIV, along with their providers.
“The HIV community and public health leaders have been working for years to get to the day when insured people who are at risk of HIV can access PrEP without cost-sharing. Unfortunately, it appears that some insurers and insurance regulators do not share our enthusiasm. I hope that will be corrected immediately,” concluded Schmid.