Private Insurance for PrEP

If you have, or are interested in, a private insurance plan for drug coverage.

The first thing you need to find out is if Truvada, its generic counterparts, or Descovy are covered under your plan?

Before you find out, stop, and consider that there is stigma and assumptions associated with taking PrEP. It may unintentionally disclose personal details about you to an insurance company or plan administrator that you may not want to put on the table right away. Insurance companies may mistakenly think you are living with HIV and are looking for the medication as treatment for HIV. They could assume that you have not disclosed a “pre-existing condition”. This could lead to the company taking a longer time to honour claims made until they determine why you are interested in it.

If this is a concern, ask your pharmacist if they can find out discretely if a specific drug is covered under your plan. Explain that you do not want to raise any flags or issues with the insurance company. Most pharmacists will use the drug’s identification number (DIN).

The DIN for Truvada, generics, and Descovy are as follows:

Truvada: 02274906¹

Teva-Emtricitabine/Tenofovir: 02399059

APO-Emtricitabine/Tenofovir: 02452006

Mylan-Emtricitabine/Tenofovir: 02443902

Descovy: 02454424

It is also a good idea to verify how much the drug will cost with your pharmacist.

Do the Math:

The Private Insurance Calculator has been specifically designed to help you understand how much your plan will cover and what you will be left with to pay out of pocket. The Worksheet will also help you evaluate a plan you are thinking of buying.

Note: This may seem basic, but if the plan costs more per month than what it pays out in coverage for a monthly dose of PrEP, and your only reason for getting the plan is to pay for PrEP, then you need to consider finding another plan. It would be cheaper to simply pay for PrEP yourself than to keep this plan. Use the Private Insurance Calculator to get the big financial picture of how a plan will impact you financially.

Understand the Claims Process:

It is important to know if you would be required to pay out-of-pocket up front for approximately $250 – $1000 for one month’s prescription before the insurance company reimburses you when you file your claim, and how long you may be left waiting for reimbursement. Some individuals are registered for direct deposit into their bank accounts with their insurance companies to reduce wait times.

Note: Most banks or credit unions put a hold on a cheque for a few days before you can access that money. This all takes some personal cash-flow planning, so that you are prepared to get by without that cash for this period.

If you have a policy that does not cover PrEP drugs, or it covers PrEP for only a very small part of the cost

If your non-insured drug costs (the bill for PrEP you are left with after the insurance plan has paid its part) are still too high, consider how you can use a public plan to assist you. Speak to a professional or community organization with experience in this field, such as ACT at 416-340-2437 or ask@actoronto.org.

If using a public plan is not an option, and you have a private plan, you may need to visit the company’s website and call the company to explore purchasing extended benefits.

If you are in a group plan (such as a plan set up for a workplace or school) there may be a plan administrator in the workplace to help you purchase additional benefits.

Again, when shopping for extended benefits, be careful about unintentionally disclosing personal information to an insurance company or plan administrator. Insurance companies may mistakenly think you are living with HIV it may take longer to process a claim or they may suspend your coverage.

To find out if there are extended healthcare benefit packages you can purchase on your own or that you can add to your current plan:

1. Understand the new benefits you are adding to your existing policy:

• How much will it cost in addition to your current coverage or as a standalone private plan?
• Is it easy to cancel?
• What are the policy’s limits? Pay attention to refill limitations on medications and how the deductibles work.

2. Talk to a pharmacist who deals with HIV medications. Pharmacists may be familiar with coverage plans and may be able to help you navigate the diverse coverage options.
3. If your only concern is about PrEP coverage, you need to know: Is it cheaper to stick to your old plan or is it cheaper to pay for extended coverage? To do this you need to add up your old insurance premium (total cost) plus medication bills; and then compare these costs to the extended plan’s higher premiums with lower medication bills. Don’t forget to consider any deductibles the plan requires you to pay first. Your deductible is the amount you are expected to pay for the medication before the insurance company begins to cover the cost; they vary greatly from plan to plan. Our Private Insurance Calculator can assist you with this.
4. There may be some other portion of the plan you can use to cover some drug costs, a “flexible benefit” that allows you to use coverage over a broad variety of health services that would include medications. Look for benefits called “discretionary health funds,” or “health spending account.” This may be particularly useful in paying a deductible for the plan or another plan you are using in conjunction with the private plan.

What if your coverage runs out unexpectedly?

For example: the insurance company suddenly declines your coverage, and you are informed of this by your pharmacist while you are standing at the counter waiting for a refill. Private insurance has been known to do this, as they have not yet fully understood the implications of PrEP medications.

The current US clinical guidelines for PrEP say to take it before, during and after a potential exposure to HIV. It is recommended to continue taking PrEP at least 28 days after a potential exposure. For this reason, you should plan for an emergency reserve of cash or medication in case your coverage is cut off.

Always consult with your doctor when stopping and starting PrEP. Research such as the IPERGAY study conducted in Montreal and France is beginning to challenge current clinical guidelines and suggests taking PrEP intermittently may also provide a high degree of protection².

¹ PrEP. March 8, 2017 retrieved from: www.hivnow.ca/prep/

² On-Demand Pre-Exposure Prophylaxis in Men at High Risk for HIV-1 Infection. New England Journal of Medicine. Retrieved March 8, 2017 at: www.nejm.org/doi/full/10.1056/NEJMoa1506273#t=article