New Guidelines for PrEP Coverage in California

Background

• PrEP (pre-exposure prophylaxis) is a highly effective medication people can take to prevent HIV

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• There are currently 3 medications used for PrEP: Descovy®, Truvada® and a generic version of Truvada®

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• Only a quarter of those who could benefit from PrEP are currently using it

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• PrEP use lowest among Black and Latino gay and bisexual men, women, young people and transgender individuals

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Background

• In June 2019, the U.S. Preventive Services Task Force (USPSTF) issued a grade A recommendation for PrEP

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• The Affordable Care Act (ACA) require most private health plans to cover preventive services recommended by the USPSTF with an A or B rating without cost sharing – does not apply to “grandfathered” health plans

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• In October 2019, Governor Newsom signed Senate Bill 159, which prohibits most private health plans from requiring prior authorization (PA) or step therapy (ST) for PrEP and PEP

Health Plan Regulation

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Majority of Private Health Plans

• Majority of private health plans in California are regulated by the Department of Managed Health Care (13.4 million people) or California Department of Insurance (1.1 million people)

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• DMHC and CDI require all state-regulated health plans to cover both PrEP medication and related clinical services without cost sharing

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• Clinical services include provider office and telehealth visits, HIV testing, kidney function testing, testing for hepatitis B and C, hepatitis B vaccination and testing for other STIs

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Majority of Private Health Plans

• Under Senate Bill 159, state-regulated health plans cannot require PA or ST for PrEP and PEP

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• However, if the FDA has approved “therapeutically equivalent” versions of a drug, the plan is only required to cover one of them without PA or ST

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• Because Truvada® and generic Truvada® are therapeutically equivalent, health plans are only required to provide one of them without PA or ST

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• Health plans must cover Descovy® without PA or ST because the FDA has not yet approved a therapeutically equivalent version

Self-Insured Employer Plans

• Self-insured employer health plans are not regulated by CDI or DMHC

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• Self-insured employer health plans are regulated by the federal Department of Labor (5.6 million people)

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• To find out what your plan is, look at your health plan Evidence of Coverage (EOC) or contact your employee benefits administrator in your employer’s HR department

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Self-Insured Employer Plans

• Self-insured employer health plans are required to cover both PrEP medication and related clinical services without cost sharing

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• Self-insured employer health plans can require PA or ST for PrEP, but the process must be expedient and allow people to start PrEP on the same day as their visit or negative HIV test

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• If the PA or ST request is approved, PrEP medication must still be covered without cost sharing

Medi-Cal

• Medi-Cal provides free health coverage for people earning less than 138% of the federal poverty level (approximately $17,775/person)

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• Medi-Cal covers PrEP medication and related clinical services without cost sharing

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• Medi-Cal does not require PA or ST for PrEP and PEP

Medicare

• Medicare is a public insurance program for older adults and people with disabilities

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• The USPSTF recommendation does not apply to Medicare, but most Medicare plans cover PrEP and related clinical services with limited cost sharing

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Financial Assistance

• If PrEP costs are not fully covered by a health plan – or if someone is uninsured – financial assistance is available through drug manufacturers and the California PrEP Assistance Program (PrEP-AP)

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• These programs are available to all California residents regardless of immigration status

Complaint Process

• People enrolled in state-regulated health plans can submit complaints to DMHC

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• If you contact DMHC and they find that your health plan is under the jurisdiction of CDI, they will forward your complaint to CDI

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• People enrolled in self-insured employer health plans can submit complaints to the federal Department of Labor

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• To find out what your plan is, look at your health plan Evidence of Coverage (EOC) or contact your employee benefits administrator in your employer’s HR department

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