Private Insurance Worksheet

Please read the “Paying for PrEP” page first.

If you’re considering purchasing private insurance, this work sheet can help you see if it is worthwhile financially.  You can also use this worksheet to see if purchasing extended benefits on a plan you already have is worthwhile. (Read the “Private Insurance and PrEP” page on this site about extended benefits). Finally having a paper copy is useful to bring with you to a PrEP provider and to consider insurance policies with an Insurance Broker.

Before you start:

Step 1: Find out how much the type of PrEP you are interested in will cost you on a monthly basis.  

-The easiest way to do this is to ask a PrEP provider if they can give you a regular monthly price for the regiment you will use.

-Another way to do this: the name of the drugs and their DIN numbers used for PrEP are on the “Private Insurance and PrEP” page or the “Getting PrEP” page – you can then search them on the Ontario Drug Benefit Formulary website for the price listing of each unit: https://www.formulary.health.gov.on.ca/formulary/  - to give you a rough estimate of price.

Step 2: Identify Public and Private Plans Available to You

Note: PrEPstart is a public plan that will cover costs for you for the first three months of using PrEP.  Read more about it on the “Paying for PrEP in Ontario” page. It gives you time to start PrEP right away and then figure out how to pay for it.

• Review “Getting HIV Meds in Ontario” page of this site.  Once you know if you can qualify for these plans, you will have a clearer picture of how much you need to cover in costs.  (Descovy is a PrEP drug that is not covered in most public plans because there is a cheaper PrEP medication on the market)
• Check if the PrEP medications you will use are covered in the private insurance plan you have or are about to get.  (See the “Private Insurance and PrEP” page on this site first to find out how.) If they are not – you need to find another plan.  

Step 3: Walking You Through the Worksheet.

Download the worksheet and print a few copies off to start figuring out the insurance costs for one year.

Collect the following information from the plan you have chosen and fill in the worksheet: 

1. Total Drug Coverage Limit - what is the maximum you can claim in drug costs for a year. Write this in the box at the bottom of your worksheet. Note: If you find the amount the plan is willing to cover is not enough to cover a year’s worth of PrEP, consider the “extended benefits” options of your policy (read more about this on the “Paying for PrEP” page)– paying for extended benefits may increase your drug coverage amount – but is it worth it?  As the cost of PrEP drugs have gone down with more generic drugs on 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.  If you are considering this question, use this worksheet to see if it makes financial sense by reflecting the more expensive “Insurance Premium Costs” with the extended benefits on the worksheet at the top left-hand column. 
2. Fill in premium (the monthly cost of the plan that you pay) X 12 months in the top left-hand column. (As mentioned above this can be the basic plan premium or the premium with the extended benefits.) 
3. Fill in co-payment X12 months in the left-hand column. (This is the difference between how much your plan will pay out and how much the prescription drug costs that you must pay).  Your insurance plan may express this as a percentage they will pay which you then deduct from the drug cost. Example: The plan pays 70% of drug costs, therefore of a $100 drug bill you pay $30 – that is your copayment.
4. Fill in the yearly Deductible at the bottom left-hand column. (This is the amount of money you pay first before insurance starts to pay out.)  
5. Total up these costs on the left-hand column.  This is your basic Yearly Insurance Plan Cost. 

Step 4: On the right side of the worksheet start figuring out the cost of PrEP for one year.

1. Find out monthly cost of PrEP X12 months and you get our total for year.
2. We outlined Public plans you can look at that might help with costs.  (See the Paying for HIV Meds page to review Public plans that might be helpful to you.)  Figure out if these plans can assist you and what they will cover. 

Note: the Ontario Trillium Drug Plan will require you to pay a deductible first and then pay the rest of costs. Example: If your yearly drug cost is $900 and your Trillium Deductible is $500 then you would reflect this on the sheet as:  $400 (Your yearly PrEP cost of $900 – $500 deductible = $400 would be paid by Trillium.)

1. Total up the right-hand column by subtracting the Public plan contributions from the total Drug Cost. These are the Total Yearly PrEP Costs that you will have reflected on the bottom of the right-hand column. 

Note: If your benefits’ drug coverage limit covers your entire drug costs for the year then you can stop here.  Compare your Total Yearly Insurance Cost to your Total PrEP Cost to see if the plan costs less than paying for PrEP directly.

But: If your benefits’ drug limit does not cover your entire bill for the year there is an added step to our process - you need to factor in any additional amount you pay out of pocket when you reach the upper limit of your benefits and you wish to keep taking PrEP for the rest of the year.  The box at the bottom of the page will help you calculate that.  This will give you a new Yearly Insurance Cost with the benefit limit and extra money from you reflected into your costs. Now, you can compare your Total Yearly Insurance Cost to your Total PrEP Cost to see if the plan costs less than paying for PrEP directly.

Contact prepaccess@actoronto.org for further assistance.