Navigating HIV PrEP and the Affordable Care Act


Confidio, Teams, Jody Hessen
Jody Hessen
Clinical Account Executive

What is PrEP

PrEP is short for Pre-Exposure Prophylaxis and is used as a preventative medication of HIV infection. The virus-killing medication is taken before exposure to HIV-1. It is recommended for:

  • People with HIV-infected sex partners
  • People who do not use condoms
  • People who inject illicit drugs

1 in 7 people with HIV don’t know they have it

PrEP is intended for those who are not currently infected with the virus but could transmit it to others through risk of exposure.

How PrEP fit into the Affordable Care Act (ACA)?

While most employer plans have forfeited their grandfathered status, there are still plans that are grandfathered. For these grandfathered plans, PrEP must be provided to plan participants at no cost because of the following reasons:

  1. Under the ACA, non-grandfathered group health plans must provide preventative therapy given an “A” or “B” rating by the US Preventative Services Task Force (USPSTF) to plan participants with no cost sharing
  2. Prophylaxis means preventative
  3. On 6/11/2019, USPSTF recommended an “A” rating for HIV PrEP

Confidio recommends that clients consult with their insurance carrier or Third-Party Administrator (TPA) to confirm that the new HIV preventive care recommendations are incorporated into their plan in time to comply with the requirements.

The Good News

The requirement of covering PrEP as a preventative medication will help improve access to those at risk by removing the cost barrier, which is good for society. An “A” letter grade indicates that the USPSTF has determined that there is a high certainty that proving the treatment without charge, will yield a substantial net benefit

When anti-viral therapy costs are reduced through use of generic products, actual cost savings are achievable, benefiting employers and other payers who retain their membership over the long-term.

Plans may also impose certain and reasonable medical management techniques, like requiring a prior authorization, which is good for payers in the short term. In addition, PBM’s will be able to provide an impact assessment for clients at their request. This will allow clients to anticipate change in cost due to implementing this requirement.

Trend and the Safety Concerns

According to Confidio’s book of business, over the past year, a trend has emerged showing preference for Descovy over Truvada. Why is this troubling considering that Descovy and Truvada cost the same amount? It is generally accepted that when person begins on a given medication, they are reluctant to make a medication change to a different medication unless there is a financial advantage. Even though there is now a generic medication for Truvada, many people on Descovy may wish to stay on it because switching to a different product would not be generically equivalent. With this trend, it is estimated that more people will remain on a brand product versus a generic if relative utilization of these two drugs would have remained constant starting a year ago

Descovy has been touted as having fewer side effects than Truvada. When used in a multi-drug regimen for treating HIV infection, Truvada can cause issues with kidneys and bones where Descovy does not. Experts do point out that in the same setting, Descovy can cause changes in markers associated with cardiovascular disease. However, these are just factors that may associated with cardiovascular disease not necessarily cardiovascular events

Is the advantage of Descovy over Truvada real? The answer is both yes and no. There has only been one study of Descovy where it was compared to the use of Truvada for PrEP, the discovery trial, the changes for both drugs were deemed not clinically relevant. Although, markers of both kidney and bone dysfunction were noted to have been affected by Truvada, actual events involving kidney or bone were not seen. In addition, experts note that the safety of Truvada when used for PrEP has been proven in multiple clinical trials. Use of Descovy would seem prudent for patients who have other risk factors for bone or kidney disease but for those who do not, Truvada seems just as safe.

PBM Coverage

Plans can implement appropriate utilization management for PrEP under the ACA. PMB’s are employing these techniques such as formulary placement, prior authorization or exception requirements. In addition, since Truvada and Descovy are used alone for HIV PrEP but in combination with other anti-viral medication for the treatment of HIV, most PBM’s are implementing a “smart edit” at the point of sale. These “smart edits” for PrEP are used at the point of sale to distinguish it from HIV treatment since only the use for PrEP requires a $0 copay.

What Can Payers Expect?

Some PBM’s will cover the generic of Truvada, while others may cover the brand and exclude the generic to achieve a lower net cost with rebates. With the ACA requiring PrEP drugs to be covered at a $0 copay, some plans may have high utilization and if their PBM covers the generic, may see a rebate loss.

A client’s current PBM contract and the PrEP drug dispensing channel will drive whether the plan is currently receiving retail or specialty rebates. The average Retail 30 per claim guarantee is $100-$200 and the average specialty per claim guarantee is $800-$1500. It is worth noting however, that per claim guarantees are not available on all pharmacy contracts and the rates do vary widely based on the contract and financials are applied to the plan sponsor.


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