PrEP Must Be Covered with No Cost-Sharing
On July 19, 2021, The Department of Labor (DOL), The Department of Health and Human Services (HHS), and The Treasury Department issued a set of Frequently Asked Questions (FAQs) that instruct health insurers and non-grandfathered group health plans to provide coverage under the Affordable Care Act (ACA) for Pre-Exposure Prophylaxis (PrEP) with no cost-sharing requirements (no deductibles, no copayments, no coinsurance) because PrEP, a daily HIV prevention option, has been designated as a “preventive service” under the ACA by the U.S. Preventive Services Task Force.
The FAQs state that health insurers and group health plans must also cover support services essential to a PrEP program with no cost-sharing requirements. These services include, HIV testing, Hepatitis B and C testing, creatinine testing, pregnancy testing, sexually transmitted disease testing, and adherence counseling as well as the cost of quarterly office visits and lab tests required to continue the prescription for PrEP.
According to the FAQs, health insurers and group health plans may cover a generic version of PrEP with no cost-sharing requirements and impose cost-sharing requirements on an equivalent brand name version, unless the generic would be medically inappropriate, as determined by a covered individual’s health care provider. In that instance, the group health plan must waive the cost-sharing requirement otherwise applicable to brand name PrEP medications.
In the FAQs, the agencies concede that health insurers and group health plans may not have fully understood earlier guidance issued in 2019 requiring coverage of PrEP with no cost-sharing requirements for plan years beginning on or after June 30, 2020. Therefore, health insurers and group health plans now have 60 days (from July 19, 2021) to comply.
No enforcement action will be taken until after the 60-day period has ended.
Full text of FAQs (DOL, HHS, Treasury, July 19, 2021)
This article is for informational purposes only and does not constitute legal advice. For additional assistance, please contact us at 202-705-3973.