Consumers Paying for HIV Preventive Care That Should Be Free
By Consumers for Quality Care, on December 17, 2024
It’s been years since the federal government mandated insurance companies cover an HIV prevention drug at no cost, yet consumers are still being charged hundreds of dollars for this life-saving medicine, according to The Washington Post.
In June 2019, a national panel of health experts concluded that HIV prevention drugs are a critical weapon in quelling the AIDS epidemic. Under provisions of the Affordable Care Act (ACA), the decision to rate pre-exposure prophylaxis, or PrEP, as an effective preventive service triggered rules requiring health insurers to cover the costs. Insurers were given until January 2021 to adhere to the ruling.
Despite the law, and recent guidance from the Biden administration instructing insurers to cover PrEP treatment without prior authorization, tens of thousands of patients are confounded by formularies that obfuscate drug costs and erroneous bills for ancillary medical services. Enforcement of these rules by the Centers for Medicare and Medicaid Services (CMS) has been slow, leading to gaps in access.
According to research from the AIDS Institute, nearly one-third of health plans don’t list PrEP as a covered preventive service, and according to the Centers for Disease Control and Prevention (CDC), at least one in five PrEP users pay out-of-pocket for treatment, which averages over $200.
Insurers argue the issues with PrEP coverage are due to incorrect billing codes submitted by health care providers, not a refusal to cover the drug. Nevertheless, this has resulted in a situation where patients often face unexpected medical bills or are forced to navigate the complexities of the health care system to receive coverage. A recent study showed that nearly half of people prescribed PrEP would not fill their prescriptions if they had to pay more than $500, underscoring the importance of making the medication fully accessible and free.
Insurers must continually ensure consumers are not receiving – and paying – unnecessary bills for services and medications that should be covered. Consumers should also be aware of their rights when it comes to preventive care.
