Health Plan Leaders Can Step Up, Lead on PrEP Services

Amida Care’s Doug Wirth says they should work with state-level officials to make sure services are covered after Biden administration’s guidance that coverage is mandatory.

Health plans leaders — especially those in charge of Medicaid managed care plans — are in a position to take a leadership role in making sure that services related to pre-exposure prophylaxis (PrEP) are covered after the Biden administration issued a guidance about the coverage last month, according to a leader of a community health plan that specializes in covering people with HIV/AIDS and other chronic conditions.

“Health plan leaders can be the thought leader working with state Medicaid directors on how to implement this in a way that plans are adequately funded and have the right the tools,” Doug Wirth, president and CEO of Amida Care in New York City, said in recent interview with Managed Healthcare Executive®.

Amida Care is a nonprofit community health plan that covers about 8,000 members in New York City, including people living with HIV/AIDS. people who are experiencing homelessness, regardless of HIV status; and people of transgender experience regardless of HIV status.

With PrEP, people at risk of contracting HIV take antiviral medication on a preventive basis to fend off the infection if they are exposed. The administration issued the guidance on July 19 to clarify that insurers must cover supporting services for people on PrEP, not just the medication itself. Those supporting services include HIV testing, hepatitis B and C testing, monitoring for any kidney damage that may result from taking the PrEP medications and adherence counseling.

“Previously, it was unclear whether PrEP-related services, beyond the medication, like provider visits, HIV tests, hepatitis and STI screening, were actually covered,” said Wirth. As a result, patients would face prior authorization delays, outright denial of coverage or cost sharing that made PrEP prohibitively expensive. Wirth described the administration’s guidance as a “game changer.”

Wirth said, though, that insurance commissioners at the state level and Medicaid directors “will need to take steps to ensure compliance and admonish insurers that ultimately break the law.”

The Medicaid programs in New York, California and Colorado are the leaders in PrEP utilization and Wirth said plans elsewhere ought to contact those state for data about access and utilization of PrEP.