Payer Barriers to PrEP

Experts in HIV provide insight into payer coverage of HIV PrEP and patient barriers for receiving PrEP.

Neil Minkoff, MD: I’ve been on the payer side, and I think there tends to be some disconnect sometimes between the wishes of the prescriber and the coverage policies of the payer. How are you guys looking at PrEP [pre-exposure prophylaxis], coverage for PrEP, who qualifies, and so on? You can paint that with a rather broad brush. We want to try to get a sense of how a payer might be looking at it. What are the dynamics on your side of the aisle?

Ryan Bitton, PharmD, MBA: I think that as Dr. Frank brought up, we’ve got 2 options that are variations of the same option. If you look at health insurance and how they’ve approached PrEP in the past decade, I think there’s been an evolution there, and it’s well accepted as something that should be covered and is coverable. Concerning a lot of payers, there aren’t hoops to jump through, in a sense, from a prior authorization perspective. We’re not going through the effort of determining, for example, does this person qualify for PrEP, or not qualify for PrEP, by some sort of complex prior authorization. I’m not saying that those don’t exist out there, but they’ve evolved, and I think that’s something that has occurred in the past few years. At the moment, I think there’s a lot of open coverage, and I think the recommendations from the US Preventive Services Task Force [USPSTF] help make things more affordable, such as $0 co-pay tiers, and things of that nature. I don’t know that payers are choosing who should qualify or who qualifies. Coverage is established and available in most plans.

Neil Minkoff, MD: I’d love to open it up a bit to some of the other folks on the panel. One of the things we deal with a lot in a number of different therapeutic and diagnostic areas is that disconnect with the payer and getting things covered, and that tends to be a barrier toward getting certain levels of, for example, rheumatoid arthritis care, or MS [multiple sclerosis] care, or things of that nature, and other chronic diseases. Is there less of a payer barrier here than in some of those other disease states based on what you’ve seen?

Jeffrey Crowley, MPH: We’re seeing a real evolution, and with the launch of the federal government’s Ready, Set, PrEP initiative, the USPSTF guidelines, I think there’s a clear thrust of the direction we need to go. But I think some of the issues aren’t about can you access the medication itself, but are we making it easy to access, such as can you get 90-day refills, or do you have to go in 30 days? There are barriers to the PrEP regimen, which isn’t just about taking a pill, it’s regular STI [sexually transmitted infection] and HIV screening every 3 months. Typically, those kinds of things can present barriers.

Carl Schmid, MBA: Now, we have seen instances of prior authorizations for certain for the PrEP drugs, and there are differences between the 2 regimens out there. One is not approved for women, and that definitely has to be factored in. Then, there are issues with one of the drug’s potential renal and bone density issues, and there’s a difference in the pill size as well. One is rather large, and the other is rather small. Perhaps, since you are taking a drug every single day for a disease that you don’t have, maybe it’s easier to take a smaller pill. It depends on how many other drugs you’re taking every day as well. We have seen some issues with prior authorizations. I would agree with Jeff, that it’s also the coverage of the other services, such as the laboratory tests and the office visits. There have been some barriers for patient cost sharing for those as well, and I’m sure we’ll talk about this later, and how that is being overcome through the US Preventive Services Task Force recommendations. Cost sharing and deductibles have been a problem as well, but now that should be alleviated.

Transcript edited for clarity.

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