News about Apretude (cabotegravir) 2-month injectable PrEP

[1stimebare]

Thanks for the reply fskn, it is truly appreciated.  How would I find out if the insurance is a grandfathered plan or not?  I have had no real complaints about my insurance so far, as it has done me quite well.  A 400k+ hospital bill left me with under 1k out of pocket.  Tho I have ER visits cost me more than that hospital bill.  And a two week physical rehab cost me more out of pocket than the two months in the hospital, which never quite made sense to me.

[BergenGuy]

8 hours ago, 1stimebare said:

Thanks for the reply fskn, it is truly appreciated.  How would I find out if the insurance is a grandfathered plan or not?

Basically, a grandfathered plan in a plan or policy that was in existence or in effect on March 23, 2010, and has remained basically unchanged.  If you purchased an individual health policy more than 12 years ago and have maintained it, it might be grandfathered.  Group plans usually change enough over time that most are not grandfathered.  A carrier or health plan is required to tell you if it is grandfathered.  If you're not sure, ask the carrier or your HR/benefits department.

[NYBBGUY58]

On 2/2/2022 at 11:55 PM, fskn said:

Information is starting to trickle in about Apretude (cabotegravir), the 2-month PrEP injection recently approved in the US. A practical "getting started" brochure for providers is out but I don't think there's an open link yet. You can read information for patients in text form, here:

[think before following links] [think before following links] https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Apretude/pdf/APRETUDE-PI-PIL-IFU.PDF#page36

The bad:

• Must be given by a medical professional

• Only supplied by a small number of specialty pharmacies

• Insurer, medical provider, specialty pharmacy, and patient assistance program (if required) need to coordinate

• Resistance to the whole drug class (integrase inhibitors) is possible if you do get HIV; HIV testing before every injection matters, as does starting a different form of PrEP if you stop injections

The good:

• In two large studies, people receiving cabotegravir injections were significantly less likely to get HIV than people receiving Truvada pills; for both, adherence matters

• Patient assistance will be available to people with private (not Medicaid, Medicare, VA, TriCare) insurance; up to $7,850/year;

[think before following links] [think before following links] https://apretudecopayprogram.com/

• 7-day window for injections

• California is already warning insurers that they cannot avoid covering this drug or impose barriers; guidance for Department of Insurance-regulated plans (Department of Managed Health Care to follow suit) with useful background about illegal practices like pre-authorization:

[think before following links] [think before following links] http://www.insurance.ca.gov/0250-insurers/0300-insurers/0200-bulletins/bulletin-notices-commiss-opinion/upload/CDI-Bulletin-2021-10-Preventive-Services-Coverage-for-HIV-PrEP.PDF

It may be a little while yet before Apretude is available, but if you are interested in injectable PrEP, this may be a good time to start talking with your medical professional.

Please share news and experiences in this thread.

This is great news! Thanks for posting it. Too late for me, obviously, but I'm so glad that PreP options continue to expand.

[1stimebare]

It's a group plan.  Retired now but still covered till Medicare kicks in and continues even after that as a back up to medicare.  

[1stimebare]

Well yesterday I was told it was not yet covered was under review.  Today I am told it will be covered but till I get the actual prescription from the doctor can't tell the costs.  It appears per insurance company that there is a 1500 a year deductible and then 30% co pay, on a bill of 2120 per dose.  Tho they say till an actual prescription is submitted everything is a mere estimate.  So looks like next step is the prescription itself and see what the real numbers look like before it is actually shipped.  So hard to get a simple answer to what seems a simple question.

[fskn]

I would recommend a two-pronged strategy, @1stimebare.

1. Enroll now in the manufacturer's patient assistance program for insured people, which should cover those out-of-pocket costs for now.

[think before following links] https://apretudecopayprogram.com/

2. Contact your state's health insurance regulator and bring up the Affordable Care Act's preventive care mandate. Unless some law or regulation requires you to first go through your insurer's internal dispute process (typically called filing an "appeal", "grievance", etc.) before the state regulator will intervene, skip the insurer's process, as it is a waste of time.

As far as waiting until the prescription is written to find out the cost, whoever told you that is incompetent. Apretude is dispensed by a pharmacy based on a prescription, but it's dispensed and delivered to your doctor's office for them to inject. You don't pick it up yourself and pay at that time. This is why it's important to enroll in the assistance program beforehand and communicate the information to your doctor's office, for them to pass along when they interact with the pharmacy that will supply your dose of Apretude. (It's a small network of specialty pharmacies, and the manufacturer has a Web portal that your doctor's office and the pharmacy must use. Your doctor's office will enter your insurance information and your copay assistance program enrollment information.)

Good luck and please keep us posted!

Edited March 17, 2022 by fskn

[1stimebare]

Got a letter today saying claim denied.  Also today got a call from the doctor it had been approved.  But unsure how much of a copay there could be till prescription written.  They did mention the company assistance program as well.  Hopefully none.

[fskn]

@1stimebare, the Affordable Care Act, and laws in some states, give you appeal rights. Even if the denial letter ends up being superseded by an approval, it's a good idea to start the appeal process now. The letter should indicate what to do, but you might have to check with your state's health insurance regulator.

You will get lots of conflicting answers from people who do not have final authority. An insurer's interest is always to cover as little as possible. The usual practice is to deny everything, even if the coverage is required by law. Clerks are trained to deny requests and are not given the knowledge or the authority to do things right. Delays, inconsistent answers, and so on, are part of the insurer's strategy. Most patients don't complain, so the strategy usually works.

Waiting to start PrEP increases your risk of HIV infection. Don't hesitate to speak up! Your state's health insurance regulator should have a Web site and a phone number where you can get information about your rights.

Edited March 18, 2022 by fskn

[1stimebare]

Today I got a letter that I was approved for Apretude for one year.  Does not say what the out of pocket cost to me will be.  I will contact the doctors office and have them nail down a price and the assuming it is reasonable, move forward.

Edited March 22, 2022 by 1stimebare

[1stimebare]

So today I called the doctors office and said order the Apretude but not to have it shipped till they quoted me a price.  The office called back and said the specialty pharmacy THEN said they can't supply it and they would have to go somewhere else.  So tomorrow I have to go back and fill out more forms and enroll in the company's financial assistance program.  No idea yet what final costs to me will be.  My God dealing with these folks is maddening.  But you were right when you said whoever I had talked to was incompetent.

[fskn]

On 3/23/2022 at 5:28 PM, 1stimebare said:

So today I called the doctors office and said order the Apretude but not to have it shipped till they quoted me a price.  The office called back and said the specialty pharmacy THEN said they can't supply it and they would have to go somewhere else.  So tomorrow I have to go back and fill out more forms and enroll in the company's financial assistance program.  No idea yet what final costs to me will be.  My God dealing with these folks is maddening.  But you were right when you said whoever I had talked to was incompetent.

I'm sorry to hear about the continuing run-around. I am, however, glad that you are enrolling in ViiV's copyment assistance program. That should be a first step for any privately-insured person who is about to start Apretude.

The out-of-pocket cost for most insured people will be zero under the Affordable Care Act's preventive care mandate. In case someone has a grandfathered health plan, or in case a plan subject to the preventive care mandate illegally tries to charge a copayment or coinsurance, and/or to apply a deductible, the program will cover those costs while the person waits for resolution of a health plan grievance and an eventual complaint to a state health insurance regulator.

Medical care that improves someone's safety and quality of life is worth the effort. The battle will only have to be fought once. The law is unequivocal and a state regulator is bound to give a non-compliant insurer a firm slap on the wrist. It just takes paperwork and time. Use the copayment assistance program in the meantime!

[hntnhole]

Thanks, fskn, for all your thoroughly professional advice.  I'm sure you've helped a lot of us with your input.  We appreciate it.  

[1stimebare]

Well looks like it will cost me $94 per shot which is seven for the year, one for each of the first 2 months and then one every two months thereafter.  But not sure if I will believe anything till after the fact.  

[1stimebare]

Well I have just been informed that there will be NO charge at all for the apretude medication, tho I may still have my regular office visit co pay.  Guess I will find that when I get to the office for the first injection.

[1stimebare]

Got my first apretude injection today.  No cost not even my usual office visit co pay.  Had to wait for an hour after the shot to make sure there was no reaction.  Go back next month for another one and after that it's once every two months.  Not considered fully protected till several weeks after the second shot.  Actually till near time for the third.  Or so I was told today.  I am the first patient at that office to have been treated with apretude.