The treatment, also called PrEP, was determined to be critical to addressing the AIDS endemic in 2019, and was given a rating under the ACA that required payers to cover the treatment. Insurers had until January 2021 to comply, but the new ruling saw resistance, prompting the July clarification.
Under the clarification, the treatments — which can range from $60 a month for generics to $2,000 a month for brand-names — and relevant medical visits should be covered.
Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, told CNN that the biggest hurdle is that payers are creating formularies that make it look like patients will need to pay for PrEP treatments, but in reality they won’t. Some payers are also listing PrEP drugs in incorrect tiers or limiting zero-cost access.
“The current system is not working,” Amy Killelea, a lawyer who specializes in HIV policy and coverage, told CNN. “There need to be actual penalties for noncompliance.”
A Labor Department spokesperson told CNN that patients with complaints should report them to the Employee Benefits Security Administration.
