The New York State Department of Financial Services (“DFS”) has instructed New York insurers to cover pre-exposure prophylaxis (“PrEP”) medication for the prevention of HIV without cost-sharing, including deductibles and co-pays.
In a “circular letter,” the DFS instructed health insurers to cover all cost-sharing, including deductibles, coinsurance, and copayments, with respect to PrEP for the prevention of HIV regardless of any discounts that drug manufacturers may offer.
The DFS said in a statement that its new guidance provided an “important protection to New Yorkers by eliminating by state law a major financial barrier many have faced in obtaining this treatment.”
The circular letter explained that New York Insurance Law Sections 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers that deliver or issue for delivery an insurance policy or contract in New York providing hospital, surgical, or medical care coverage, except for a grandfathered health plan (meaning coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e)), to provide coverage for preventive care and screenings at no cost-sharing. New York insurance law requires, among other things, that issuers provide coverage for evidence-based care and screenings with an “A” or “B” rating in the current recommendations of the U.S. Preventive Services Task Force (“USPSTF”) at no cost-sharing.
On June 11, 2019, the USPSTF issued an “A” rated recommendation that clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. According to the full recommendation statement, the USPSTF found convincing evidence that PrEP is of substantial benefit for decreasing the risk of HIV infection in persons at high risk of HIV infection, either via sexual acquisition or through injection drug use. The USPSTF also found convincing evidence that adherence to PrEP is highly correlated with its efficacy in preventing the acquisition of HIV infection.
According to the DFS, coverage for PrEP for the prevention of HIV infection is vital to ending the AIDS epidemic. The DFS observed that, prior to the USPSTF recommendation on PrEP, grandfathered and non-grandfathered plans that covered prescription drugs should have been covering PrEP under their prescription drug benefit, but could impose cost-sharing.
Now, however, because offering PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition is an “A” rated recommendation, the DFS said that issuers, other than grandfathered health plans, must provide coverage for PrEP for the prevention of HIV infection at no cost-sharing pursuant to Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3).
The DFS said that it “expects issuers, other than grandfathered plans, to provide coverage for PrEP with effective antiretroviral therapy at no cost-sharing to persons who are at high risk of HIV acquisition as soon as possible, but no later than January 1, 2020, for policies or contracts that are issued or renewed on or after that date.”
Learn more: Circular Letter.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].