June 25, 2020

“PrEP Test” to be required as Preventive Service for Persons at risk of HIV Acquisition

On June 11, 2019, the The United States Preventive Services Task Force (USPTF) added pre-exposure prophylaxis (“PrEP”) for persons at high risk of HIV acquisition as a “preventive care” service health plans must provide.

Under the ACA, non-grandfathered health plans are required to provide coverage for preventive care at 100% without cost sharing. Health plans must begin covering PrEP medications on the first day of the plan year beginning one year after the date the USPSTF adopts a recommendation.

USPSTF is charged with determining what services are considered preventive care.  They may revise the list of services from time to time. USPSTF’s recommendation details which individuals are considered “at high risk of HIV” acquisition.

  • Fully insured plans should be able to rely on their insurance issuers to implement this coverage. However, it’s best practice to verify with the issuer.
  • Self-insured plans may need to amend their plan language unless the plan automatically covers all required USPSTF-required preventive care.  Perhaps of greater concern to self-insured plans will be the cost of providing this coverage…which can be quite expensive.
  • Plan sponsors will want to consult with their TPAs, PBMs, and actuaries to assess the impact of this new requirement (if any) on plan financing.
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