Best Insurance To Cover Prep

[cintarius]

So now that PrEP is available, what is the best insurance to cover PrEP? I'm sure not all insurance plans are equal. Which ones have you had experience with that cover the whole cost? I know that Gilead has a $200 copay help, but I want to talk exclusively about regular insurance and what your experience has been like with them while trying to get PrEP. Are some insurance plans more "gay friendly" than others? Inquiring minds want to know!

[fskn]

I have a grandfathered (pre-Obamacare) individual plan from Kaiser. My copayment for a 90-day supply of Truvada is $35. This, in turn, is reimbursed by Gilead. My copayment for as many tests as I need in one session is $10. (The FDA prescribing guidelines for Truvada for PrEP call for various tests to be done at least quarterly.)

The same insurer will offer so many different plan designs through so many different channels that it is impossible to say which insurer is best. Some plan designs have no prescription coverage at all. Some have high annual deductibles. Some have high copayments for prescriptions and tests. Some cover only 30 days' worth of medication with each drug copayment and only a single test with each laboratory copayment. Some require pre-approval for expensive services. And so on...

An equally important consideration is who will be providing your medical care. What primary care doctors, infectious disease specialists (if the primary care doctors are backward and unwilling to oversee PrEP care; N.B.: HIV and ID specialists have no experience or particular training for providing preventive care to HIV-negative patients), laboratories and pharmacists are affiliated with the plan?

Good providers are aware of current drug approvals, protocols, and research -- crucial in the case of PrEP. They have online systems that make it easy for you to get tests, access test results, and communicate periodically with your doctor. Billing and payment are convenient and accurate, with no buck-passing between insurer, primary care doctor, specialty doctor, and pharmacy.

In this respect, Kaiser is ideal. Insurer and provider are one in the same. Any Kaiser primary care doctor need only log in to the computer system to read a standard protocol for PrEP intake and ongoing care. Standing laboratory orders are stored online and you can get your tests done at any Kaiser facility in your region. Test results are available online, often the same day. Instead of wasting time and money on routine office visits, you can communicate with the provider who oversees your PrEP care by secure e-mail. Coverage for PrEP is addressed during the intake process, and there is only one party to pay.

The only drawback is that Kaiser pharmacies, unlike CVS, Walgreens and other commercial operations, cannot accept Gilead/McKesson copayment assistance cards. Instead, you must print out a reimbursement form, fill it out, attach your prescription receipt and label, mail everything in, and wait for a check to be mailed back to you. The fact that your doctor can use an online system to have your Truvada prescription ready for you in the time it takes you to get from his or her office to the pharmacy downstairs, more than makes up for this.

Edited October 10, 2014 by fskn

[seaguy]

I am not sure this is the right place to ask what plans are best because plans are often specific to geographic areas, employers, and stuff like that.  So I might have a great plan that covers PrEP here in WA but you can't get this plan over in New York.  That is the other thing each state has its own laws mandating coverage that in some cases goes above and beyond Federal laws.  You don't list your location in your profile so I can't offer advice for your state.  I used to work in insurance for state govt so I am familiar with things.  

 

Just would not want you getting info on great plans only to find you can't sign up cause that carrier is not in your state.

I have a grandfathered (pre-Obamacare) individual plan from Kaiser. My copayment for a 90-day supply of Truvada is $35. This, in turn, is reimbursed by Gilead. My copayment for as many tests as I need in one session is $10. (The FDA prescribing guidelines for Truvada for PrEP call for various tests to be done at least quarterly.)

The same insurer will offer so many different plan designs through so many different channels that it is impossible to say which insurer is best. Some plan designs have no prescription coverage at all. Some have high annual deductibles. Some have high copayments for prescriptions and tests. Some cover only 30 days' worth of medication with each drug copayment and only a single test with each laboratory copayment. Some require pre-approval for expensive services. And so on...

An equally important consideration is who will be providing your medical care. What primary care doctors, infectious disease specialists (if the primary care doctors are backward and unwilling to oversee PrEP care; N.B.: HIV and ID specialists have no experience or particular training for providing preventive care to HIV-negative patients), laboratories and pharmacists are affiliated with the plan?

Good providers are aware of current drug approvals, protocols, and research -- crucial in the case of PrEP. They have online systems that make it easy for you to get tests, access test results, and communicate periodically with your doctor. Billing and payment are convenient and accurate, with no buck-passing between insurer, primary care doctor, specialty doctor, and pharmacy.

In this respect, Kaiser is ideal. Insurer and provider are one in the same. Any Kaiser primary care doctor need only log in to the computer system to read a standard protocol for PrEP intake and ongoing care. Standing laboratory orders are stored online and you can get your tests done at any Kaiser facility in your region. Test results are available online, often the same day. Instead of wasting time and money on routine office visits, you can communicate with the provider who oversees your PrEP care by secure e-mail. Coverage for PrEP is addressed during the intake process, and there is only one party to pay.

The only drawback is that Kaiser pharmacies, unlike CVS, Walgreens and other commercial operations, cannot accept Gilead/McKesson copayment assistance cards. Instead, you must print out a reimbursement form, fill it out, attach your prescription receipt and label, mail everything in, and wait for a check to be mailed back to you. The fact that your doctor can use an online system to have your Truvada prescription ready for you in the time it takes you to get from his or her office to the pharmacy downstairs, more than makes up for this.

Group Health in WA is very similar to Kaiser it's an HMO that employs it's network providers, has it's own pharmacies but if your in rural areas where they don't have a Group Health owned clinic they contract with providers you can see same with pharmacies.  Group Health and Kaiser both are big on preventive care so PrEP ought to be a no brainer for them to cover.

[rawfuckr]

In this respect, Kaiser is ideal. Insurer and provider are one in the same. Any Kaiser primary care doctor need only log in to the computer system to read a standard protocol for PrEP intake and ongoing care. Standing laboratory orders are stored online and you can get your tests done at any Kaiser facility in your region. Test results are available online, often the same day. Instead of wasting time and money on routine office visits, you can communicate with the provider who oversees your PrEP care by secure e-mail. Coverage for PrEP is addressed during the intake process, and there is only one party to pay.

 

 

Just let me add another testimony about Kaiser and PrEP. My experience with them has been great. Kaiser is my 3rd PrEP provider so I have some points of comparison.

A few things I love about Kaiser and Kaiser+PrEP:

• You can message doctors directly either from website of from phone app. While other practices may have this ability, in fee-per-visit practices emailing your doctor is discouraged and they want you to come in for everything, as it's the only way they make their money, most of the time, long explanations on emails are frowned upon. In Kaiser doctors get paid fixed salary regardless, so they don't care if your interaction is in person or through an online message. Many questions can be answered through a message. I've thrown them lots of questions and all of them have been carefully read and answered.
• Standing lab orders. If you are on the PrEP program you can get STD checks (HIV,syphilis, chlam and ghono (3 sites)) every 3 weeks. You don't have to talk with anyone, they are on the computer. Just walk in into the lab and get it done. This is great if you've been particularly slutty and want to get checked. 
• Pharmacy is integrated between mail orders and pickup orders. True, you can only use them for your drugs, but seems to work fine for me.

I'm with an individual plan from the Covered California exchange and there doesn't seem to be much of a difference with group plans, unlike the other insurers who have pared down their provider network to nothing. 

[curiousone]

Anthem HMO covered me fully. No copay either through certain doctors.

[cintarius]

I am not sure this is the right place to ask what plans are best because plans are often specific to geographic areas, employers, and stuff like that.  So I might have a great plan that covers PrEP here in WA but you can't get this plan over in New York.  That is the other thing each state has its own laws mandating coverage that in some cases goes above and beyond Federal laws.  You don't list your location in your profile so I can't offer advice for your state.  I used to work in insurance for state govt so I am familiar with things.  

 

Just would not want you getting info on great plans only to find you can't sign up cause that carrier is not in your state.

Group Health in WA is very similar to Kaiser it's an HMO that employs it's network providers, has it's own pharmacies but if your in rural areas where they don't have a Group Health owned clinic they contract with providers you can see same with pharmacies.  Group Health and Kaiser both are big on preventive care so PrEP ought to be a no brainer for them to cover.

I live in California, Bay Area. But you're probably right. With so many different insurance laws a site wide discussion probably isn't the most effective means of debating the fine points. But I know little about health insurance being a "young invincible" who has rarely had to rely on health care. Thanks!

[seaguy]

I live in California, Bay Area. But you're probably right. With so many different insurance laws a site wide discussion probably isn't the most effective means of debating the fine points. But I know little about health insurance being a "young invincible" who has rarely had to rely on health care. Thanks!

Well I can tell you one thing CA is always on the forefront when comes to laws that protect or help consumers and mandating coverage of PrEP is probably something CA will end up doing along with WA I hope if the insurance companies start playing games with covering it.  You should check out the covercalifornia website open enrollment is coming up for the Obamacare plans, which would include medicaid since CA is a state with the expanded medicaid.

 

Came across this list of CA Bay Area PrEP websites that might be helpful for you http://stdhivtraining.org/PrEP_Websites.html

Edited October 11, 2014 by seaguy

[MedicalMetsFan]

I just started PrEP in August. I'm in the southeast US (North Carolina) with Cigna for insurance. $35 a month.

 

My PMD is very open. He has HIV positive patients, but didn't have anyone on PrEP. I was his first. I explained that I had read everything I could and talked to a few people, and wanted to go on it. He didn't even bat an eye. Said he needed to read up on and spent about 5 minutes doing that; then we talked about what he expected: HIV test every three months, baseline liver and kidney functions, repeat at 3 months, then every six months thereafter. He literally said, "You're an informed guy. If you want to do something in your healthcare, let me know. We'll make it happen." (I'm a healthcare professional myself.)

 

I actually suspect he might be gay, but can't confirm it. He's fantastic.