How the HIV PrEP Initiative Will Impact Pharmacy Benefits Plans

Top 3 Things You’ll Learn

  • The prevalence of HIV in the United States and how PrEP can help lower the rate of infections
  • What is changing with HIV preventive drugs under the Ready, Set, PrEP initiative
  • How to prepare your self-funded clients for PrEP’s potential impact on their pharmacy benefits plan costs

Roughly 1.1 million people in the United States have HIV, and nearly 40,000 more become infected with the virus each year, according to the U.S. Centers for Disease Control and Prevention. Data shows that Pre-Exposure Prophylaxis (PrEP), a daily pill containing two oral antiretroviral drugs, can reduce the risk of HIV infection by up to 99% in high-risk people who take the drug consistently. However, the use of PrEP across the country is still relatively low.

To combat this trend, President Trump introduced the Ready, Set, PrEP initiative with a pledge to end the HIV epidemic in the U.S. by 2030. A key part of the Federal program involves increasing PrEP utilization by making the medication more accessible to patients. While this move benefits people at high-risk of contracting HIV, it could have lasting implications for your self-funded clients if they are not prepared for the impact.

HIV PrEP costs $1400-$3000 per month and will be a covered preventive med in 2021. See how your pharmacy benefits plan could be impacted.

What’s Changing

Under the Affordable Care Act, private health plans are required to cover preventative services that the U.S. Preventive Services Task Force grants an “A” or “B” rating. As part of the Ready, Set, PrEP initiative, the task force changed the status of PrEP, giving it an “A” grade. This change enables members covered under private health insurance plans to obtain PrEP at no cost with a prescription.

Truvada and Descovy are the only two approved PrEP drugs on the market and cost between $1,400 – $3,000 for a 30-day supply. It’s worth noting that Truvada cost half of that amount in 2004, and there is no sign of a generic drug launching until about 2021. Proper oversight will be critical to maintaining an affordable pharmacy benefits plan going into 2021.

Impact on Payers

Your self-funded clients will be required to cover PrEP at no cost to their members, effective on January 1, 2021 pharmacy benefits plans. This change could have a potentially significant financial impact on plans with high utilization of HIV medications and/or at-risk populations. Specifically, under the program, you can expect to see increased program advocacy and advertising to get people to take these medications. With a $0 cost to members, your clients can expect to see increased PrEP adoption among their members and a corresponding uptick in plan spend.

With the change, some PBM’s will no longer include HIV medications on their specialty drug list. Your clients may experience a change in their prescription drug benefits pricing and rebates. Pharmacy claims for PrEP also will no longer be subject to utilization management protocols your clients may have in place for high-cost medications. As you review your clients’ pharmacy benefits plan performance data this year, be sure to have detailed insight into their current PrEP utilization so that you can understand the specific impact this change will have on their bottom line.


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