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PrEP for HIV Prevention: Essential for Ending the Epidemic, but Out of Reach for Many

Jaime Rosenberg
Despite pre-exposure prophylaxis (PrEP) being crucial for preventing new HIV infections and working toward an end to the epidemic, the treatment is still out of reach for many.

Because many consumers are not aware of the policy when they sign up for their plan, and because the copay card maxes out at $4800 annually, “this means people are finding out that their plan or pharmacy benefit manager implemented this midyear when they go to pick up their PrEP prescription and they’re hit with a $1600 bill because they’ve been using their copay card, which hasn’t been doing anything to help them meet their deductible,” said Killelea.

In an effort to clear some of these hurdles, starting September 1, Gilead will increase its annual benefit for Truvada to $7200, up from the orignal $4800. Starting this month, those who qualify for the Medication Assistance Program are eligible for 12 months, rather than 6 months. 

"At Gilead, we are committed to ensuring that people at risk of HIV have access to Truvada for PrEP tablets," said a Gilead spokesperson in an email exchange with The American Journal of Managed Care®. "We support comprehensive payer coverage and maintain the Gilead Advancing Access program for qualified underinsured and uninsured people in the US who cannot afford their medications. This includes our Truvada for PrEP co-pay assistance program for commercially insured individuals and the Medication Assistance Program, which provides free medication for those who qualify based on financial need."

In order to help consumers navigate the muddy waters of paying for PrEP, advocacy groups have implemented their own programs to overcome some of the barriers. “NATSAD has been finding different ways that health departments and providers in their jurisdictions can utilize varying financing mechanisms and partnerships,” said Killelea.

Another major part of the effort has been insurance access—ensuring people know if they’re eligible for Medicaid or if they’re eligible for subsidized insurance through the marketplace, she explained.

A growing number of state health departments have also launched PrEP drug assistance programs through state funding to offer PrEP for those who otherwise don’t have access.

In May, the FDA expanded the indication for PrEP—originally intended for those age 18 and older—to include those who weigh at least 77 pounds. With the expanded indication comes another potential barrier: adolescents who are still under their parents’ insurance and want to access PrEP.

For these patients, as well as those with private insurance that won’t cover the pill, the uninsured, and those who can’t access patient assistance programs, Washington, DC’s, health department steps in and provides Truvada starter packs for free, said Kharfen.

“We will do same day start-ups of PrEP. We’ll give people the medication then, because when they say they’re ready now, we don’t want them to be told that they have to wait,” he explained. “Our approach has been: if someone is at that moment and they’ve made that decision, we want to be able to affirm that decision right then and there.”

Over the past 3 years, the department has spent close to a million dollars on the treatment. However, with Washington, DC’s, ambitious goal of having 8000 people on PrEP at any 1 year by 2020, and no available generics, there is a question of whether providing free PrEP for those who need it will be sustainable.

Kharfen also cited a lack of understanding surrounding PrEP among managed care plans, such as awareness that PrEP has dual indications for both the treatment and prevention of HIV. “We still get plans saying, ‘Well, this medication is used for treatment,’ and therefore they won’t necessarily give coverage,” he explained.

“Managed care plans should see the benefit associated with this,” said Kharfen. “When we’re talking about lifetime HIV treatment costs [between] $375,000 and $400,000, PrEP is much more affordable than that, so there’s a financial incentive to cover PrEP.”

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