HIVnow – Private Insurance & PrEP

Private Insurance and PrEP

Before you get private insurance involved always check to see if you can qualify with a public plan as well. “Getting HIV Meds in Ontario ” goes through a list of public plans and the “Ontario Trillium Drug Plan ” page details one of the key plans for covering medications in Ontario.

This page examines some issues you should consider if you decide to use private insurance. If you are interested in purchasing insurance, an insurance broker can help you with finding a new plan that has drug coverage, but it must make financial sense to you and all the questions below need to be understood. Read this page first and then use our “Private Insurance Worksheet” to help you make financial sense of PrEP.

Can you access a pre-existing insurance plan? (…or maybe more than one plan?)

Most people know if they have insurance; however, what people usually don’t know are the details of their plan or if a family member may also have insurance that covers them too. A person can use two private plans to cover more cost. You can also use a public plan in combination with private insurance plans to reduce costs.

Its important to make time to read your plan(s), your pharmacist may not have access to all plan details when you come to the pharmacy. Pharmacists may be familiar with popular plans they deal with frequently, but they only get acceptance or rejection notices of a claim from an insurer in real time when they are trying process a prescription. (They may get a reason for the rejection such as: “special authorization form needed”, “maximum days of supply” (i.e. will only cover 30 days worth of meds at a time, instead of 90 days). A pharmacist can join a phone call you make to your insurance plan to help you ask questions, if they have the capacity to provide this service.

When reading your plan or looking at a new plan you should note:

the premium (the amount you pay monthly for the plan)
the deductible (It is the amount you are expected to pay for the medication before the insurance company begins to cover the cost.);
co-pay / co-payment (a fixed amount your plan may charge per prescription);
your maximum limit for claims (specifically drug cost claims);
the percent of a claim paid by the plan; and
when the benefits period starts and stops. (This can reset the amount of claims you are entitled to make to zero when a new period starts.)

Note: If you are planning on taking a more expensive drug such, as Descovy, maximum drug cost limits are particularly important to understand, as you can exhaust a plan too soon. Also good to know is if the plan allows the pharmacy to directly bill the cost of drugs to the insurance company; if not, you will have to pay first and then get reimbursed from the insurance company.

Does your plan(s) cover PrEP medications?

Most people find out by asking a pharmacy to do an instant reversable test claim using their insurance card. Pharmacists usually have enough practical experience to check multiple generic drugs used for PrEP to see if a plan is rejecting only one drug or all PrEP drugs. Community pharmacists with a background in HIV medications may even know if a drug is regularly declined but in fact can be granted access by an insurance company with a special authorization form (i.e. Dr. prescribing Descovy instead of Truvada due to strain on kidney functioning).

If you do have to speak with an insurance company directly, ask specifically if the drug is covered with it’s DIN number (see below) – you do not have to get into details of why you are taking it. Keep it short and concise with the insurance company. Here is a list of drugs to enquire about:

PrEP medications and their DIN numbers:

Teva-Emtricitabine/Tenofovir: 02399059
APO-Emtricitabine/Tenofovir: 02452006
Mylan-Emtricitabine/Tenofovir: 02443902
PMS-Emtricitabine/Tenofovir 02461110
Mint-Emtricitabine/Tenofovir 02521547
Jamp-Emtricitabine/Tenofovir Disoproxil 02487012
Auro-Emtricitabine/Tenofovir 02490684
AG-Emtricitabine & Tenofovir Disoproxil 02496356
Truvada (name-brand): 02274906
Descovy (tenofovir alafenamide/emtricitabine) DIN: 02454424

Is Privacy Important to You with Your Insurance?

Considering how the confidentiality of private plans operate may be important to you – specifically when the plan is a group plan provided through work. Larger employers typically use the insurance company to administer the plan, in this case no one at work ever sees claims associated with an individual. (It would be a good idea to check if individual claims are seen by anyone in the case of a smaller employer, although this is now becoming more rare.)

In terms of a plan, where there is more than one beneficiary (e.g. a spouse and their partner), often all the people in a shared plan can see each other’s claims. This can be a parent seeing a child’s claims or a spouse seeing a partner’s claims for medications and services.

On a final note, in a shared family plan, often the insurance company will only pay one person (the main person insured/principal beneficiary), if the plan does not have direct billing from the pharmacy, the money for PrEP will be deposited to another person’s account if you are not the main person insured. That person will know how you are using the insurance and the costs of your use.

Any of this can make an individual uncomfortable with using a plan, so it’s important to understand the privacy within individual plans.

The Bottom Line is Cost – Do the Math:

The Private Insurance Worksheet 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.

This may seem basic, but if the insurance plan costs more per month than what it pays out in coverage for a monthly supply of Descovy (a more expensive PrEP drug) for example, and your only reason for getting the plan is to pay for PrEP, then you need to consider if there are:

pharmaceutical company programs that can help you with cost (e.g. Gilead has a benefit card for Descovy for a limited time) (ask medical professionals – especially pharmacists),
flexible benefits in your plan that allows you to use coverage over a broad variety of health services including medications (read through your plan’s details),
public plans that can help you in combination with your private insurance (check out ” and the “” pages of this site),
extended benefits on the same plan you already have that you can purchase (read through your plan’s details or talk to the insurance company or the plan administrator),
cheaper PrEP medications (ask a medical professional), and
another completely different plan (ask an insurance broker to find a new plan).

Flexible Benefits:

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.

Extended Benefits:

As the cost of PrEP drugs have gone down with the entry of more generic drugs into the market this option has become less useful – especially if you have a private plan (instead of a group plan). It is very likely this option will not make financial sense if you are on generic forms of Truvada. (i.e. The cost of the extended benefits will still be more than the cost of the drugs because Truvada generics are cheaper.)

For a private plan, you may need to visit the insurance company’s website and call the insurance company to explore purchasing extended benefits. If you are in a group plan (a work or school plan) there may be a plan administrator at work/school 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. (i.e. People can make value judgements about using the medications for safer sex – and some companies can see you as “high risk”.)

To consider an extended healthcare benefit package you should understand the new drug benefits you are adding to your existing policy, and there are other specifics you should note:

How much will it cost (the additional premium) 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.)

If your only concern is about PrEP coverage, you should ask yourself if it is 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 the PrEP part of the bill you are paying out of your own pocket and co-payments; and then compare these costs to the extended plan’s higher premiums with lower PrEP bills. (Don’t forget to consider any deductibles the plan requires you to pay first. Our can assist you with this.)

Once Your Private Insurance Starts – Working Smarter with Your Benefits

Extended Benefits:

Called “discretionary health funds,” or a “health spending account”, may be particularly useful in paying a deductible for the plan or another plan you are using in conjunction with the private plan. This benefit is more likely to be present in a group plan. (i.e. your work or school plan) Note: Here is one example often forgotten about – even though Trillium is a public plan, it has deductibles based on your income – those deductibles can be paid using this benefit. The other good thing to know: this benefit is usually accounted for separately in its own account and usually does not affect your drug benefit allowance accounting.

Deductibles:

There are very few PrEP providers who pay the deductible partially or even fully, but they do exist. Talk to someone about how to deal with the deductible cost if it’s of concern to you to the point that you cannot get PrEP. There are a few PrEP providers who pay these costs systemically and others who are understanding and consider it if they see financial hardship – basically its important to voice if it is a concern for you.

Direct Deposit:

If you have no problems with your bank and you are the main person being insured under your plan then take advantage of directly depositing money from your insurance company to your own bank account to speed up being paid. This is a great arrangement when you must pay costs first and then get reimbursed. The alternative is waiting for a cheque in the mail, and some banks and credit unions may put a hold on a cheque after you deposit it. However, if you are not the main person being insured and are covered in a shared plan with your spouse/partner, the insurance company may not be able to deposit to your account. Often the insurance company will only pay the main person insured/principal beneficiary – which results in your money for your PrEP being deposited to another person’s account (i.e. your partner or parent). That person will then have to transfer that money to you. This takes some coordination and paying attention to bank account details – given there may be other claims going on – so keep records of when a claim was submitted and how much it would be so that you can remind the other person to look for the payment.

Avoiding No Coverage Surprises:

What you should keep track of when you are using the plan (especially if you are using more than one plan)

when and how much you are claiming with each plan,
when a plan pays you for each drug claim, and
a running total of how much you are being paid out of each plan’s drug benefit allowance.

Private insurance plan administration web sites can keep track of some of these, but if you don’t use the insurance site regularly it may take a while for you to find the relevant details. Taking your own notes to compare are useful. Community pharmacists have pointed out that unfortunately it is not uncommon for people to be surprised when they have run out of their drug benefit money in their plan. That’s why its important to keep a running total of your drug costs.

Managing for a No Coverage Surprise and You Stop Taking PrEP:

It’s important to have a back up plan if the insurance company declines your drug coverage while you are standing at the pharmacy counter waiting for a refill and are first informed of this by your pharmacist.

This is where the text for the back of your card should go.

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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