HIV PrEP Drugs Now Covered 100% by Health Plans

In what seems like ages ago, back in the summer of 2019, the United States Preventive Services Task Force (“USPSTF”) recommended that health plans cover pre-exposure prophylaxis (“PrEP”) for persons who are at high risk of HIV acquisition.  Under the Affordable Care Act (“ACA”), USPSTF recommendations must be covered by non-grandfathered health plans with no cost-sharing for covered persons for plan years beginning after June 19, 2020.  This requirement means that most employer-sponsored health plans must soon provide the specialty PrEP HIV drugs at no cost to participants for all participants at risk for HIV exposure.

The new recommendation from USPSTF is based on research that found the use of PrEP can substantially reduce the risk for persons at high risk of HIV infection.  The USPSTF gave PrEP a grade A recommendation.  An “A” rating means the recommendation falls under the ACA rules for preventive medicine and must be offered at no cost to participants.  Even though PrEP drugs are considered specialty drugs, and have prices that correspond to that classification, they must be treated like any other preventive medicine no later than your next plan year beginning on or after June 19, 2020.

As specialty drugs, the cost impact to plans to cover these drugs could be significant.  Industries that have higher at-risk populations, such as health-care where needle sticks may be more common, will likely see the largest cost impact.  To aid in cost management, plan sponsors should consider implementing medical management features such as prior authorization for specialty drugs in order to lessen the cost impact.

Pre-authorization would confirm the participant is HIV negative and that the medication was prescribed to prevent, rather than treat, HIV. In addition, if your plan currently excludes all specialty drugs from coverage, a plan amendment should be done to include PrEP drugs under the medical portion of your plan.

If you have any questions about how to implement this new drug coverage in your plan or about any other benefits issues, please contact any of Graydon’s employee benefits team.

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