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PrEP must now be totally free under almost all insurance plans, government says

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Thefederal government has announced that almost all health insurers must cover the HIV prevention pill, known as PrEP, or pre-exposure prophylaxis, with no cost sharing — including for the drug itself and, crucially, for clinic visits and lab tests.

What We Know:

Truvada or Descovy, the two approved forms of PrEP, should now be totally free for almost all insured individuals. A physicia must persuade an insurer that Descovy in particular is medically necessary for any specific patient to qualify for zero cost sharing for that drug’s use as HIV prevention.

The guidance that the Centers for Medicare and Medicaid Services, along with the Department of Labor and the Department of the Treasury, sent to health insurers Monday indicated that insurers have 60 days to comply with the mandate. The rule says insurers must not charge copays, coinsurance or deductible payments for the quarterly clinic visits and lab tests required to maintain a PrEP prescription.  Insurers were already required to stop charging out-of-pocket fees for the medication by Jan. 1, 2021, at the latest.

PrEP access for individuals with low income are the result of the U.S. Preventive Services Task Force granting this form of HIV prevention an “A” rating in 2019. Under the Affordable Care Act, such a rating for preventive health care services, including annual physicals or tests for various diseases such as HIV itself, means they must be covered by almost all insurers at no cost to the insured patient. Obamacare at work.

This is a developing story and will be updated.


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