Per the Affordable Care Act (ACA), employer-sponsored health plans will be required to cover the HIV specialty drugs Pruvada and Descovy at 100% beginning their first plan year following June 19, 2020. The requirement follows a United States Preventive Services Task Force (USPSTF) recommendation that health plans cover pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

  • If your plan currently requires that all pharmacy program specialty drugs undergo prior authorization, then these drugs will already be subject to authorization and no action is necessary (other than covering these medications at 100% when a covered person is found to be HIV negative).
  • If your plan does not require prior authorization on specialty drugs, it is recommended that a prior authorization requirement be added specifically for these medications.
  • If the prescription drug provisions of a plan specifically exclude all specialty drugs, these medications should still be listed as covered under the medical provisions of the plan.

If a generic form of these medications becomes available for use in the future, the prior authorization process can be re-evaluated at that time.

Under the ACA, USPSTF recommendations must be covered by non-grandfathered health plans with no cost-sharing for covered persons, when obtained through a preferred provider, or through any provider if the plan does not utilize a preferred provider network. To implement this requirement, plans will have to be able to distinguish between circumstances when these medications must be covered at 100% and when the plan’s prescription copayments can apply.

Fortunately, the ACA allows for the implementation and use of reasonable medical management techniques when it comes to covering these medications. This means that it is possible to add a prior authorization requirement to confirm that the covered person is HIV negative and that the medication was prescribed for preventive reasons, rather than the treatment, of HIV. This would assist the plan in knowing when these medications must be covered at 100% and when the plan’s prescription copayments would apply.

For information on how your health plan currently covers specialty drugs, contact your Account Management team. Account Managers are also able to assist with adding a prior authorization requirement to the plan, if needed.

The full recommendation, including who is determined to be at high risk for HIV acquisition, is available at the USPSTF website.