USPSTF RECOMMENDATION FOR PREP

BULLETIN 23-EX-2 TO: ALL INSURERS ISSUING ACA HEALTH POLICIES IN GEORGIA FROM: JOHN F. KING INSURANCE AND SAFETY FIRE COMMISSIONER DATE: FEBRUARY 1, 2023 RE: USPSTF RECOMMENDATION FOR PREP ______________________________________________________________________________ On July 19, 2021, the Departments of Labor, Health and Human Services, and the Treasury released new guidance for health insurance plans clarifying that the ACA requirements to cover PrEP (pre-exposure prophylaxis) without cost-sharing should be applied by plans consistent with the purpose of the U.S. Preventive Services Task Force (USPSTF) recommendation to reduce risk of HIV transmission for people who are at high risk of acquiring HIV. Therefore, the recommendation applies not just to the drug itself but also to the ancillary test and services required to begin and maintain a prescription for PrEP. The purpose of this Bulletin is to provide guidance for all insurers writing marketplace insurance in Georgia. What must plans cover without cost-sharing? • At least one FDA-approved PrEP medication, which can be a generic equivalent. However, to the extent that a plan limits which PrEP medications are covered without cost-sharing, it must ensure “an easily accessible, transparent and sufficiently expedient exception process” that enables access to other PrEP medications when a provider determines that the covered PrEP medication is not medically appropriate for a given enrollee. • The USPSTF Final Recommendation Statement encompasses FDA-approved PrEP antiretroviral medications, as well as the following baseline and monitoring services: o HIV Testing o Hepatitis B and C testing o Creatinine testing and calculated estimated creatine clearance (eCrCI) or glomerular filtration rate (eGFR) o Pregnancy Testing o Sexually Transmitted infection (STI) screening and counseling o Adherence counseling • Plans and issuers are also required to cover without cost-sharing office visits associated with each recommended preventive service applicable to the participant, beneficiary, or enrollee when the service is not billed separately (or is not tracked as individual encounter data separately) from the office visit, and the primary purpose of the office visit is the delivery of the recommended preventive service. Recommendation to Carriers: Ensure that applicable plans are updated on your respective website to indicate that the PrEP and ancillary-related services are classified as preventive care and available to enrollees without costsharing requirements. _____________________________________________ JOHN F. KING INSURANCE AND SAFETY FIRE COMMISSIONER STATE OF GEORGIA