Estimated Uncovered Costs For HIV Preexposure Prophylaxis In The US, 2018

Abstract

The cost of HIV preexposure prophylaxis (PrEP) medication and care is a key barrier to PrEP use. Using population-based surveys and published information, we estimated the number of people with uncovered costs for PrEP care among US adults with PrEP indications, stratified by HIV transmission risk group, insurance status, and income. Accounting for existing PrEP payer mechanisms, we estimated annual uncovered costs for PrEP medication, clinical visits, and laboratory testing based on the 2021 PrEP clinical practice guideline. Of 1.2 million US adults with PrEP indications in 2018, we estimated that 49,860 (4 percent) of them had PrEP-related uncovered costs, including 32,350 men who have sex with men, 7,600 heterosexual women, 5,070 heterosexual men, and 4,840 people who inject drugs. Of those 49,860 people with uncovered costs, 3,160 (6 percent) incurred $18.9 million in uncovered costs for PrEP medication, clinical visits, and lab testing, and 46,700 (94 percent) incurred $83.5 million in uncovered costs for only clinical visits and lab testing. The total annual uncovered costs for adults with PrEP indications were $102.4 million in 2018. The proportion of people with uncovered costs for PrEP is less than 5 percent among adults with PrEP indications, but the magnitude of costs is significant.

Commercial Determinants of Access to HIV Preexposure Prophylaxis

“…McManus et al found that coverage for PrEP medications was high among qualified health plans, which is consistent with reports suggesting that most people can access PrEP at low or no cost . However, the study’s results are also consistent with prior evidence that it is often not the out-of-pocket costs but the complexity of obtaining financial coverage—through health plans for insured people or assistance programs for uninsured people—that deters people from using PrEP .…”

“…The 2 medications were priced at over $20 000 annually per person during the study period, 3 making coverage essential for those accessing PrEP through insurance plans.McManus et al 3 found that coverage for PrEP medications was high among qualified health plans, which is consistent with reports suggesting that most people can access PrEP at low or no cost. 4 However, the study's results are also consistent with prior evidence that it is often not the out-of-pocket costs but the complexity of obtaining financial coverage-through health plans for insured people or assistance programs for uninsured people-that deters people from using PrEP. 5 The authors 3 found that 15% to 20% of plans placed PrEP medications on specialty tiers and that prior authorization requirements were common, particularly for emtricitabine/tenofovir disoproxil fumarate, the older medication.…”

Estimating the potential value of MSM‐focused evidence‐based implementation interventions in three Ending the HIV Epidemic jurisdictions in the United States: a model‐based analysis

“…MSM and transgender women) participants located in Miami were less likely to utilize PrEP beyond completion of a demonstration project study compared to those in San Francisco [61]. This highlights the critical role that insurance access plays in limiting the potential scale of PrEP interventions [20,62,63]. As health insurance coverage continues to be a substantial barrier in limiting the potential scale of PrEP, Medicaid expansion and PrEP Drug Assistance Programs improve equity in access to care in addition to policies that increase PrEP coverage and reduce related costs in insurance plans, and interventions which offer PrEP at no cost regardless of insurance coverage or immigration status [22,23,64,65].…”