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