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Insurance Department Highlights Importance of HIV PrEP Medication for HIV Prevention, Coverage under the Affordable Care Act

12/01/2022

Harrisburg, PA – Today, on World AIDS Day, Pennsylvania Insurance Department (PID) Policy Director Katie Merritt joined representatives from the Pennsylvania Commission on LGBTQ Affairs and Hamilton Health Center to highlight the importance of HIV pre-exposure prophylaxis, or PrEP, medication for HIV prevention, and to detail insurance coverage of the drugs under the Affordable Care Act.

"We want to remind consumers that the federal government requires most insurers to cover HIV PrEP medication at zero cost to the consumer, if the consumer is at high risk of HIV acquisition," said Merritt. "Nobody should ever forgo medically necessary preventive medication or services because of cost, and the department is committed to ensuring that all health insurance plans under its jurisdiction are following the requirements to cover PrEP and related services without cost sharing."

"Zero-cost" means that the consumer will not be charged an out of pocket copayment, deductible or coinsurance for these drugs. Tests, doctor visits, and other services directly related to obtaining PrEP and included in the PrEP billing, should also be covered with no out of pocket cost to the consumer. 

This coverage requirement also includes brand names, such as Truvada and Descovy. However, for these brand name drugs, insurers may require prior authorization to confirm that a brand name drug is medically necessary before the consumer qualifies for zero cost savings.

"As Hamilton Health Center is set to launch prevention programming in February 2023 that includes PrEP navigation and clinical care, we are thankful that PrEP is covered by insurance in our state," said Alexandria Gannett, HIV and Reproductive Services Director at Hamilton Health Center. "This ensures that our most vulnerable patients will have access to this life-saving preventative medication."

"To end the HIV epidemic in Pennsylvania and the United States, we need to work together to increase awareness, reduce stigma, and improve access to live-saving medications like PrEP, said Dr. Katharine Dalke, commissioner for the Pennsylvania Commission on LGBTQ Affairs. "Thankfully, PrEP is covered by insurance in our state and is accessible to patients who need it."

Any consumer who has received HIV PrEP medication and was charged a copayment, coinsurance, or deductible should contact their health insurer to request a refund. The number for the insurer can usually be found on the back of the health insurance card. Consumers are also encouraged to contact the Pennsylvania Insurance Department if they have any questions on coverage of HIV PrEP medication or need assistance.

Consumers who need health care insurance are encouraged to explore their coverage options at Pennie®, the commonwealth's official online health insurance marketplace. Pennie's Open Enrollment Period is happening now and runs through January 15, 2023, with December 15 marking the deadline for coverage beginning January 1, 2023. For those enrolling between December 16 and January 15, coverage will begin February 1, 2023.

This annual Open Enrollment Period is an opportunity for Pennsylvanians to take advantage of substantial savings on 2023 coverage. Nine out of 10 Pennie customers qualify for financial savings, meaning most are eligible for subsidized monthly premiums on their health insurance. Currently, nearly 40% of Pennie customers pay less than $75 a month.

Consumers with questions on coverage of HIV PrEP medication, or any questions on their health insurance may contact the department online at insurance.pa.gov or call the department's Consumer Services Bureau at 1-877-881-6388.


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