Insurance Companies Are Failing to Cover Medication to Prevent HIV

By Consumers for Quality Care, on May 18, 2022

According to reporting by Axios, insurance companies are not covering the medication to prevent HIV and the required associated care, which is in violation of the Affordable Care Act (ACA).

The drug, called pre-exposure prophylaxis or PrEP, is highly effective at preventing HIV – more than 90 percent. The brand-name version can run $20,000 a year. For those on the medication,  regular doctor’s visits and lab work are required. PrEP and related care are both covered by the ACA as a preventive treatment.

However, if the care is not billed correctly, consumers can be left with surprise medical bills. As a result, many then stop taking the medication, putting them at risk of contracting HIV.

“They’ve been on PrEP and then all of a sudden, there’s a new obstacle,” said Jeffrey Crowley, the director of Infectious Diseases Initiative at the O’Neill Institute. “They need to get prior authorization or they used to get their meds for 90 days and now they can only get them for 30 days. All of these hassle factors cause people to fall off.”

Anthony Cantu, who works at a health clinic helping patients access PrEP, began taking the medication last summer. Even with all his knowledge, he has still been sent surprise bills. So far, he has received more than $500 in bills for lab work that should have been covered.

Insurers must continually ensure consumers are not receiving – and paying – unnecessary bills. Consumers should also be aware of their patients’ rights when it comes to preventive care.