Implementing cost sharing for HIV prevention drugs could leave many unprotected

February 9, 2024

Figure 1: Patients projected to abandon PrEP

Source: Dean, et al Health Affairs, February, 2024 LINK

The Fifth Circuit Court of Appeals will take up the Braidwood Management v. Becerra case next month, and their decision may invalidate the Affordable Care Act’s requirement that employer sponsored health plans provide coverage without cost sharing for pre-exposure prophylaxis (PrEP) medicines. The daily oral medications Truvada and Descovy (tenofovir/emtricitabine) and the every-other-month injection Apretude (cabotegravir) are prescribed for those at high risk of HIV infection. PrEP medications decrease risk of HIV infection by as much as 99%. The annual acquisition cost of these drugs ranges from $200 for the generic version of Truvada to over $20,000 for brand name drugs.

If the Fifth Circuit rules in favor of the plaintiffs, employers may also impose cost sharing on other preventive services including screening for lung cancer, colon cancer (ages 45-49) and hepatitis C, and medication to prevent recurrence of breast cancer.

Some states are considering allowing for PreP therapy without a physician prescription, which may help to improve access.  The governor of California just signed a bill to allow PrEP therapy to be dispensed over the counter by pharmacists if specific conditions are met.

Researchers in Health Affairs examined data from a large pharmacy claims database to see how many people filled their PrEP prescriptions during 2015-2019 when cost sharing was in place. They used this data to project how many patients prescribed PrEP would fill prescriptions depending on the level of cost sharing imposed. They found that over 95% of people were likely to obtain PrEP drugs if cost share remained at $0, while as many as 40% of members would stop obtaining the medication if out-of-pocket costs increased to over $500. (Figure 1) Further, the researchers projected that rates of HIV infection would be over twice as high in those who abandoned PrEP medications due to out-of-pocket costs. (Figure 2)

Figure 2: New HIV diagnosis within 365 days

Source: Dean, et al Health Affairs, February, 2024 LINK

Implications for employers:

• Even if the Circuit Court eliminates the ACA requirement to fully cover PrEP to prevent HIV infections, employers wishing to maintain member protection can continue to cover these medications without cost-sharing, including for HSA-qualifying HDHPs since the Internal Revenue Service provided guidance that USPSTF recommendation will be considered preventive care even if not required by the ACA.

• Health plan sponsors can lower the cost of PrEP by providing coverage without out-of-pocket costs for only generic tenofovir/emtricitabine, although PBMs have generally maintained some brand name drugs with high associated rebates on their formularies.

Thanks for reading.  You can find previous posts in the Employer Coverage archive

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