Regional Disparities in Qualified Health Plans’ Prior Authorization Requirements for HIV Pre-exposure Prophylaxis in the United States

Abstract

IMPORTANCE With the goal of ending the HIV epidemic in the United States, access to HIV pre-exposure prophylaxis (PrEP) is essential to help curb new HIV infections. There has been differential uptake of PrEP by region, with the South lagging behind other regions. Discriminatory benefit design (benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment) through prior authorization requirements could be a systemic barrier that contributes to the decreased PrEP uptake in the South.OBJECTIVES To investigate whether there are regional disparities in prior authorization requirements for combined tenofovir disoproxil fumarate and emtricitabine for qualified health plans (QHPs) and to assess whether any QHP characteristics explain the disparities. DESIGN, SETTING, AND PARTICIPANTSThis design was a cross-sectional study of QHPs offered in the 2019 Affordable Care Act Marketplace. The QHPs studied included all Affordable Care Act-compliant individual and small-group market plans in the United States. EXPOSURES The primary exposure was the 4 census regions (Northeast, West, Midwest, and South). Additional covariates included other plan characteristics. MAIN OUTCOMES AND MEASURES Prior authorization requirement for combined tenofovir disoproxil fumarate and emtricitabine at the QHP level. RESULTSIn total, 16 853 QHPs were analyzed (18.2% in the Northeast, 19.5% in the West, 25.0% in the Midwest, and 37.3% in the South). Overall, 18.9% of QHPs required prior authorization for combined tenofovir disoproxil fumarate and emtricitabine. This percentage varied by region, with 2.3%, 6.2%, 13.3%, and 37.3% of plans requiring prior authorization in the Northeast, West, Midwest, and South, respectively. Compared with QHPs in the Northeast, QHPs in the South were 15.89 (95% CI, 12.57-20.09) times as likely to require prior authorization, whereas the Midwest and West were 5.69 (95% CI, 4.45-7.27) and 2.65 (95% CI, 2.02-3.47) times as likely, respectively. Other plan characteristics did not account for the regional variation. CONCLUSIONS AND RELEVANCECompared with QHPs in the Northeast, QHPs in the South were almost 16 times as likely to require prior authorization for PrEP, and the reasons for these disparities are unknown. The prior authorization requirement is a possible barrier to PrEP access in the South, which is the region of the United States with the most annual new HIV diagnoses. There is limited regulation of QHPs' prior authorization requirements. Federal-or state-level health policy laws may be necessary to remove this system-level barrier to ending the HIV epidemic in the United States.

Trends in Buprenorphine Coverage and Prior Authorization Requirements in US Commercial Formularies, 2017-2021

“…The Ideon database includes formularies used by midsize and large group non-Marketplace plans, small group and individual Marketplace plans, and off-Marketplace small group and individual plans. Although Ideon lacks enrollment data for midsize and large group non-Marketplace plans, the small group and individual Marketplace plans associated with formularies in our sample collectively accounted for 8.6 million enrollees per year (eMethods 1 in the Supplement has additional details) . For all individual and small group plans and most large group plans, Ideon collects information on network size, defined as the number of clinicians and facilities participating in the network.…”

Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018–2020

“…QHPs have significant flexibility to design their own formularies. As a result, drug coverage varies across QHPs and high cost sharing, specialty drug tiering (a system used by insurance companies to categorize high cost prescription drugs used in the treatment of complex medical conditions, like HIV), and excessive prior authorization requirements (the process of requiring a clinician to obtain approval from a patient’s health insurance prior to treatment) limit ART and HIV pre-exposure prophylaxis access [ 18 – 21 ]. These access barriers may reflect discriminatory benefit design where insurance plan characteristics prevent or delay people with complex conditions from obtaining appropriate treatment [ 18 – 20 ].…”

Primary care provider prep prescribing practices : southern United States

“…QHPs in the South were almost 16 times as likely to require prior authorization as compared to QHPs in the Northeast. The Midwest and West were only 5.69 and 2.65 times as likely respectively(McManus et al, 2020). The reasons for these disparities are unknown; however, the higher rates of prior authorization for PrEP in the South may be a barrier to PCPs prescribing PrEP.…”

“…co-pay coupons by not allowing them to count towards patients' deductibles(Luthra & Gorman, 2018;McManus et al, 2020). The overall effect of this is that patients are now responsible for an increasing share of their PrEP costs(O'Bryne et al, 2019).Another potential barrier to PrEP access is that insurance coverage under the Patient Protection and Affordable Care Act (PPACA) varies based on the plan.…”

“…The reasons for these disparities are unknown; however, the higher rates of prior authorization for PrEP in the South may be a barrier to PCPs prescribing PrEP. Discriminatory QHP designs that mandate stringent prior authorization requirements may be a systemic barrier that contributes to low PrEP prescribing by PCPs in the Southern U.S (McManus et al, 2020)…”