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Prepping for PrEP: What a New "A" Rating for Truvada Means for Employers

The U.S. Preventive Services Task Force (USPSTF) issued an “A” recommendation for the use of pre-exposure prophylaxis (PrEP) for HIV prevention, as well as HIV screening for individuals at risk for contracting HIV and all pregnant women. USPSTF “A” recommendations are the gold standard for evidence review for preventive health care services; this will expand access for your employees to valuable health care services and increase plan costs.

What Does this Mean for Employers?

  1. The ACA Requires That Non-Grandfathered Group Health Plans Must Cover This Service, Without Cost-Sharing, Effective for Plan Years Beginning on or After June 11, 2020 (January 1, 2021 for Calendar Year Plans.)

According to the Business Group’s 2019 Large Employers’ Health Care Strategy and Plan Design Survey, 38% of large employers have at least four tiers in their pharmacy plan design, with greater cost-sharing for high cost drugs like Truvada. With the “A” recommendation, employers will soon be required to cover Truvada at no out-of-pocket (OOP) costs for employees. For employers that currently provide coverage for PrEP pre-deductible via a preventive drug list, the impact on employee OOP will be less pronounced, but potentially still significant based on their plan design.

  1. Utilization and Costs to the Employer Plan Associated with PrEP Will Likely Rise in the Short Term.​

According to the Express Scripts 2018 Drug Trend Report, HIV was the 5th highest cost drug therapy class for commercial plans. Not all of that spend, which includes therapies for those who have contracted HIV, is for PrEP, but costs will likely rise as financial barriers to accessing the medication are eliminated for plan members. Gilead’s patent on Truvada, which lists for almost $2,000 per month, will expire in 2021 and generic entry to market may mitigate increases in plan costs associated with this new “A” rating.

2018 Spending on Top 0 Therapy Class Drugs Across Express Scripts' Commercial Plans (per-member-per-year(

  1. More of Your Employees Should Receive Evidence-Based Treatment.

According to the Centers for Disease Control and Prevention (CDC), taking PrEP reduces the chance of contracting HIV during sex by 90% and for injected drug users by 70%. It is standard therapy for individuals at high-risk of contracting the disease. Expanded access is a boon for employers looking to create insurance designs that favor first-dollar coverage of effective treatments. 

Transitioning Your HIV/AIDS Strategy When PrEP is Available Without Cost-Sharing

Based on the USPSTF’s “A” Rating, employers should consider the following actions:

  • Treat this as any other preventive service for other diseases. HIV/AIDS is commonly understood as a disease that affects men who have sex with men and those who inject drugs, but others are affected as well. For example, African Americans--particularly women--are also disproportionately impacted. The Southeast has the highest rates of HIV/AIDS and untreated HIV/AIDS in the U.S.
  • Communicate this change to employees, especially employee interest groups that are specifically referenced in new USPSTF recommendations, such as screening for new and expecting moms (for this population, emphasize its importance to their health and the health of their child), and treatment for members of the LGBTQ community and African American individuals.
  • Consider incorporating HIV/AIDS into anti-stigma campaigns.
  • Ask your health plan to assess network coverage for facilities that are culturally competent in prescribing and monitoring use of PrEP.
  • Ask your pharmacy benefit manager to estimate the impact the “A” rating will have on your plan costs and utilization. This should incorporate potential market entry of generic competitors to Truvada in 2021/2022.

Employers interested in continuing the conversation on value-based insurance design and specialty pharmaceutical costs should consider joining the Business Group’s Committees on Evidence-Based Benefit Design and Pharmacy Benefits & Specialty Medicine.

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