Comments to Colorado Dept of Health Care Policy & Financing supporting the prohibition of prior authorization for HIV treatment and prevention in Medicaid
The HIV+Hepatitis Policy Institute is a leading national policy organization promoting quality and affordable healthcare for people living with or at risk for HIV, viral hepatitis, and other serious and chronic health conditions. We thank you for the opportunity to comment on the proposed reintroduction of prior authorization for HIV treatment and prevention in Colorado’s Medicaid program after the expiry of state prohibitions on prior authorization for these antiretrovirals in July 2026. [1]
We urge Colorado to maintain the prohibition of prior authorization for HIV treatment and prevention in Medicaid.
Prior authorization is a well-documented barrier to care. A recent KFF survey has found that 4 in 10 insured adults with a chronic condition report that prior authorization has delayed or denied necessary treatment [2]. A recent report by the HIV Medicine Association confirmed that inefficient and cumbersome prior authorization processes cause dangerous delay and disruptions for people requiring HIV treatment and preventive care and their providers. It also found that prior authorization disrupts access to guideline-recommended care [3].
Timely access to guideline-recommended HIV treatment and prevention is critical for both individual and public health. This understanding is now widely reflected in federal and state policy prohibiting prior authorization for HIV treatment and prevention. For example, prior authorization is not generally permitted for any antiretrovirals in Medicare Part D – the only drug class among the Six Protected Classes to be given this specific protection [4]. More recently, this protection has been extended to all pre-exposure prophylaxis (PrEP) medications, now covered in Medicare Part B [5]. Federal guidance also prohibits prior authorization for the purpose of steering PrEP users to any particular PrEP drug in non-grandfathered commercial insurance plans as well as in Medicaid Alternate Benefit Plans [6], and a plethora of state legislation and regulation has imposed similar requirements at the state level.
These policies align with rapid scientific advancement. HIV treatment has evolved significantly since the introduction of effective combination HIV regimens in 1996. Newer regimens are far more tolerable, easier to adhere to, and have fewer side effects and drug-drug interactions than earlier regimens. They also present a higher barrier to the development of mutations that allow the HIV virus to resist treatment, and are now frequently available as a single pill or even as a long-acting injectable. Similarly, HIV prevention has evolved since the introduction of the first daily oral PrEP regimen in 2012, now a generic, with options now including a twice-annual injectable, with more innovations in the pipeline. Prior authorization frequently targets these newer, more expensive regimens, creating barriers to the most effective and appropriate care.
Reinstating prior authorization would disproportionately harm the most vulnerable. While prior authorization for antiretrovirals harms all Coloradans affected by HIV, the greatest burdens will fall on people, communities, and safety-net clinical providers who lack the resources to navigate new prior authorization barriers. Colorado’s existing ban on prior authorization is a model that should instead be preserved. Reversing this protection – particularly within Medicaid – would risk a reversal of the state’s progress towards ending the HIV epidemic at a time when paperwork and cumbersome recertification processes are already increasing.
If you have any questions or comments, please contact Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute at cschmid@hivhep.org or (202) 462-3042, or Kevin Herwig, Health Policy Manager, HIV+Hepatitis Policy Institute at kherwig@hivhep.org or (617) 666-6634.
[1] https://legiscan.com/CO/text/SB189/id/2775490
[5] https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/part-d-benefits-manual-chapter-6.pdf (section 30.2.5)
[6] https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=377&ncdver=1
[7] https://www.cms.gov/files/document/faqs-implementation-part-68.pdf