Completely free PREP in USA

[fskn]

Although I have compassion for GLBT people who live in rural or backward (not necessarily the same thing) areas, the truth is that people who care about their health factor in their health situation when deciding where to live.

My favorite examples are HIV prevention and treatment norms in San Francisco. There is no other place in the world where same-day initiation of antiretroviral therapy is universally available to people who test positive for HIV. All major public, private, and charitable/community-based/non-profit health providers in the City participate in a Getting to Zero consortium that has set this as the standard. The consortium even relies on "detailing", an old-fashioned practice whereby more experienced medical practitioners teach less experienced ones, to reach small medical offices (most of which are affiliated with larger, GTZ-aware networks like Sutter Health anyway).

Other jurisdictions are starting local GTZ groups, but none can match the comprehensive reach of San Francisco's. The City's latest annual HIV epidemiological report (also a unique effort, unmatched anywhere in the US for detail and accuracy) reveals that virtually all of the people newly-diagnosed with HIV in San Francisco last year started ART the day they received their positive test results. Faster ART initiation means a smaller viral reservoir, which could benefit patients if HIV "cure research" keeps advancing. For the gay community at large, faster ART initiation means shorter time to viral suppression, which means less HIV transmission.

San Francisco's GTZ consortium has also made same-day PrEP initiation standard.

Last but not least, anyone who gets a routine HIV test through the San Francisco Department of Public Health gets a pooled qualitative PCR HIV viral load test. This innovative approach, whose only other use in the US is for blood donations, strikes a compromise between speed and cost. Pooling blood from multiple patients makes it affordable to use a viral load test for HIV diagnosis. (Only if the pool tests positive do the individual samples all have to be tested.) This test can detect HIV within days of infection, rather than a week or two, for the newest and best available antibody+antigen test commonly used elsewhere. Faster detection means faster treatment.

If you are a gay man, your sexual health outcomes will be better in San Francisco than anywhere else.

My favorite counterexample is senior citizens who choose to retire to small towns in the countryside, but soon start complaining because the rural hospital has closed, the doctor has left town, they have to drive or be driven to dialysis or to the pharmacy, etc., etc. Choosing to live in a small town makes no sense if someone has significant medical needs, or is in a group that, statistically speaking, has significant medical needs. (This is not to say that I approve of rural hospital closures, only that it is physically impossible to provide the same standard of medical care in small towns as in large population centers.)

[oinker]

I have insurance Medicare primary and united health secondary. Through nyship. Ny. State  I am charged a copay of  30  for descovy

[Sfmike64]

10 hours ago, oinker said:

I have insurance Medicare primary and united health secondary. Through nyship. Ny. State  I am charged a copay of  30  for descovy

I believe that the no charge for the drugs only applies to generic (i.e. Truvada but in generic form). Yes, that's correct: "Plans and insurers can, for instance, opt to cover only the generic version of PrEP without cost sharing while requiring cost sharing for branded versions (e.g., Truvada)."

You should sign up for the Gilead co-pay assistance.[think before following links] https://www.gileadadvancingaccess.com/copay-coupon-card

They will cover the co-pay for you. You should NOT be charged any co-pays for labs required for continuing to take Descovy (or Truvada/generic Truvada) for PREP. If you are, your insurance and provider are doing something wrong.

[PigFaggot2904]

2 hours ago, Sfmike64 said:

I believe that the no charge for the drugs only applies to generic (i.e. Truvada but in generic form). Yes, that's correct: "Plans and insurers can, for instance, opt to cover only the generic version of PrEP without cost sharing while requiring cost sharing for branded versions (e.g., Truvada)."
 

From my experience, Truvada is now generic so insurers would prefer patients use that for PrEP.  For me, personally, Truvada's side effects re: bone issues caused me to stop taking it a couple years ago.  Decided to resume PrEP recently, but this time, asked for Descovy, explained side effects from Truvada, etc.

My insurer required a Prior Authorization for Descovy, which my clinic sent in & it was approved.  After it was approved, I ordered the medication online, and I had a $0 copay.  I was expecting a copay of a couple hundred, based on how my prescription insurance works....

Based on this, I would presume PrEP--regardless of medication--is covered 100%.  But insurers might make you jump through hoops if you want Descovy.

[BootmanLA]

3 hours ago, PigFaggot2904 said:

From my experience, Truvada is now generic so insurers would prefer patients use that for PrEP.  For me, personally, Truvada's side effects re: bone issues caused me to stop taking it a couple years ago.  Decided to resume PrEP recently, but this time, asked for Descovy, explained side effects from Truvada, etc.

My insurer required a Prior Authorization for Descovy, which my clinic sent in & it was approved.  After it was approved, I ordered the medication online, and I had a $0 copay.  I was expecting a copay of a couple hundred, based on how my prescription insurance works....

Based on this, I would presume PrEP--regardless of medication--is covered 100%.  But insurers might make you jump through hoops if you want Descovy.

That's correct. Insurers must cover PrEP for their customers, but they're allowed to require the generic if one is available for the brand name prescribed. They can also have a "formulary" (that is, a list of approved drugs for each kind of treatment) that doctors are expected to use if the patient expects insurance to cover that medication. Almost invariably, however, a doctor may specify a non-formulary drug if there's a medical reason to do so, with the approval of the insurer. In order to have it covered, the provider submits a request for Prior Authorization (an advance "OK" to use the non-formulary drug). If approved, it gets treated like any other preventative care medication (ie no cost/no copay). 

[Sfmike64]

Yet another way that American health care is completely insane and ruled by insurance bureaucracy instead of actual medicine.

We spent $800BN on health care administration in 2017.  Four times per capita spending in Canada. It's a completely insane amount of money. 1/3 of overall health care spending is administration.

[think before following links] https://www.reuters.com/article/us-health-costs-administration/more-than-a-third-of-u-s-healthcare-costs-go-to-bureaucracy-idUSKBN1Z5261

[Sfmike64]

This is an explanation of benefits for my latest generic Truvada prescription, which arrived yesterday. My truly awful insurer is Anthem Blue Cross (NEVER CHOOSE THESE HORRIBLE PEOPLE IF YOU HAVE CHOICES OF INSURANCE). 

=======================
Show Me the Math

Average Retail Price  $3,680.35

Our Discounted Price  $71.43

Amount Plan Paid  -$71.43

Your Responsibility  $0.00

Plan Savings  $3,680.35
=======================

Instead of simply saying "this prescription costs $71 for a 30 day supply there's all of this absurd discount nonsense so you feel like you're getting some kind of bargain. To someone from Europe this must look completely bonkers. Because it is. It's complete lunacy. But Americans LOVE A BARGAIN. So it looks like I got a 99% discount! 

But of course I got nothing of the sort, and neither did the insurance company.

[PozCubBtm]

Question for this group...A friend of mine is on prep and switched insurance companies due to a job change....he's had the same labs run each time he goes in for his PREP renewal. This last time when he went in for his labs his insurance company is charging him for the lab work. His labs not only include the HIV test but also for other STD's, a liver test, and his Dr does a viral load test to see if there is any sign of HIV that the PREP may be suppressing. I thought that with the affordable care act that not only are the meds covered but lab test should also be covered....His insurance company is fighting this and he's been frustrated. He asked me if I knew anything about it and I told him I would check and see.

[Sfmike64]

A few insurance plans are not subject to the ACA, this is very unusual, but it does happen. For 99% of people, this should be helpful.

"These items and services are HIV testing; hepatitis B and C testing; creatinine testing and kidney function tests; pregnancy testing; STI screening and counseling; and adherence counseling to help ensure that PrEP is used as prescribed."

He should push back hard on this and involve his HR department (if one exists and he gets insurance through work as many people do). This guidance about PREP has existed for almost two years and was talked about extensively before that.

[think before following links] https://www.healthaffairs.org/do/10.1377/forefront.20210728.333084/

[Rillion]

Insurance company is only required to pay for the minimum lab work required for the PreP protocols. It sounds like your doctor might be ordering additional tests above and beyond the guidelines. I ran into this issue with one of my tests, doctor was orderong a more extensive (ie expensive) version of a test and the insurance company was balking at paying for it.

Also there could be an issue of what diagnosis and code the doctor is using, since that PreP is only approved for high risk individuals and there is some specific code for that for insurance purposes.

[Rillion]

Last October my primary care physician that was overseeing my prep quit (think she moved out of the area). My previous pcp wasn't willing to supervise prep so referred me out to an infectious disease specialist (I had no luck finding one that was taking new patients hence why I found a new pcp instead). So rather than interview multiple new doctors, I'm trying out mistr. So far it's been relatively easy. Sending off my completed at home testing kit today. Had my online visit with a doctor yesterday. So far pretty easy, which I like.

[PozCubBtm]

On 1/18/2023 at 8:47 AM, Rillion said:

Insurance company is only required to pay for the minimum lab work required for the PreP protocols. It sounds like your doctor might be ordering additional tests above and beyond the guidelines. I ran into this issue with one of my tests, doctor was orderong a more extensive (ie expensive) version of a test and the insurance company was balking at paying for it.

Also there could be an issue of what diagnosis and code the doctor is using, since that PreP is only approved for high risk individuals and there is some specific code for that for insurance purposes.

Thanks I will let him know....this is not for me, I am already hiv+ its my friend who is on prep...

[BootmanLA]

On 1/18/2023 at 9:47 AM, Rillion said:

Also there could be an issue of what diagnosis and code the doctor is using, since that PreP is only approved for high risk individuals and there is some specific code for that for insurance purposes.

Actually, I don't think that's not *quite* correct any longer. FDA guidelines now approve its use for adolescents and adults "at risk" (not "high risk") for infection through sex or IV drug use. 

Moreover, with the approval of PrEP as a preventative measure that must be covered at no cost to the insured under any insurance policy subject to ACA guidelines, there is (apparently) a lot less scrutiny over PrEP prescriptions and insurers, in general, seem to be accepting a doctor's word that the patient is at risk and this is an appropriate preventative measure.