By Barbara Hawes and Cory Jorbin
With renewals that are effective July 1, 2020 and after, employer health plans will be required to cover the costs of HIV PrEP (or pre-exposure prophylaxis) drugs to prevent the transmission of HIV infection.
It’s not very often that new drugs are added to those whose coverage by health plans is mandatory under the Affordable Care Act (ACA) – at 100%, with no co-pay, co-insurance or deductible. This addition was recommended in June, 2019 by the U.S. Preventive Services Task Force (USPSTF), with a cost impact on health plans that is still uncertain – especially given bigger issues like the COVID-19 pandemic overshadowing it.
The addition of HIV PrEP to the USPSTF list aligns with the Trump administration’s pledge to end the HIV epidemic in the U.S. by 2030. Over 1 million people live with HIV today and 40,000 Americans are infected with the virus annually. Another 1.2 million people are at high risk of acquiring HIV. But fewer than 80,000 have been prescribed the preventive medication, 2016 data show.
HIV PrEP drugs are manufactured by Gilead Sciences under the brand names Truvada and Descovy. (Both are also FDA-approved and used for treatment of HIV; health plan coverage for this purpose is unchanged.) As a preventive therapy, they can reduce the risk of infection by as much as 92% if taken consistently by high-risk individuals. But they are high-cost specialty drugs, listing at almost $21,000 annually – and, until now, with high copayments or coinsurance.
Whether your plan is fully insured or self-insured, you can expect to see some degree of cost impact at renewal with this requirement, especially if your industry is one with higher-risk employee populations that are more transient and less traditional or, as in the case of healthcare, more prone to needlestick risks.
However, other variables may play a role, too. For example, only Truvada and Descovy have been indicated for HIV prevention and one, Truvada, will be available as a generic, perhaps as soon as September, 2020. That presumably would also occur with some level of price drop – and health plans would only be required to cover the costs of one drug, not both.
If your plan is fully insured, you may see an uptick in utilization with expanded prescribing, but unless you have heavy utilizers or are in high risk industries, the impact on renewal pricing should be relatively modest.
Self-funded plans can expect to absorb the member cost-share of these drugs only for approved PrEP use. Your pharmacy benefit plan administrator should provide guidance on your current utilization in this category and availability of forecast modeling. And given the application of this change to HIV PrEP, check on measures to ensure 100% coverage only applies to appropriate members.
Some employers may seek to opt out of providing ACA-mandated coverage for drugs like HIV PrEP and contraceptives. Those that do must notify their plan administrators and be aware of potential regulatory compliance risks.
HUB International’s team of Employee Benefits consultants, including members of its Pharmacy Practice and compliance organization, are available to help you manage the issues facing today’s benefits programs.