[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-404486-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-404486-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","schmid-healthhiv-prep-insurance-coverage-march-2021","Schmid-HealthHIV-PrEP-Insurance-Coverage-March-2021","","March 25, 2021 briefing on private insurance requirements for HIV prevention using PrEP. It explains what PrEP is, how it is prescribed and monitored, and why it substantially lowers HIV risk. The document outlines Affordable Care Act preventive-coverage rules, USPSTF and January 2021 requirements for Essential Health Benefits, and summarizes federal and state actions affecting coverage without patient cost-sharing.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/schmid-healthhiv-prep-insurance-coverage-march-2021/404486/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/schmid-healthhiv-prep-insurance-coverage-march-2021/404486.png","ImageObject",300,407,{"name":42,"@type":43},"SANS","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-29","2026-09-27",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is PrEP and how is it taken?","Question",{"text":63,"@type":64},"PrEP is pre-exposure prophylaxis for HIV prevention. It is an FDA-approved, once-daily medication regimen with required follow-up visits and periodic lab monitoring.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What insurance rules require PrEP coverage without patient cost-sharing?",{"text":68,"@type":64},"The Affordable Care Act requires non-grandfathered individual and small-group plans to cover Essential Health Benefits, including preventive services, with no cost-sharing. In January 2021, all EHB plans must cover PrEP without cost-sharing.",{"name":70,"@type":61,"acceptedAnswer":71},"What issues were found during the 2021 plan review?",{"text":72,"@type":64},"The review included spot checks of formularies during Open Enrollment. While many plans complied and offered at least one PrEP prescription without cost-sharing, some plans were not compliant and had transparency problems.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},404486,1790917813,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},"Religion & Spirituality",20,"religion-spirituality",{"id":117,"doc_module":4,"doc_module_name":25,"category_name":120,"show_sort_weight":117,"slug":121},"World Cup","world-cup",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":123,"slug":125},10,"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":139,"language":140,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":12,"update_tm":144,"read_time":145,"preview_page_count":4},962090760505,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","New Private Insurance Requirements For PreP: No Patient Cost-sharing  \nNational Coalition for LGBT Health  \nMarch 25, 2021  \nCarl Schmid  \nExecutive Director  \nWhat is Pre-Exposure Prophylaxis (PrEP)?  \n• Approved by FDA in 2012 and recommended by CDC in 2014 for HIV prevention  \n• Once daily medication regimen (three drugs now approvedTruvada, Descovy & Generic Truvada)  \n• Requires office visits, HIV & hepatitis B tests & other periodic lab tests monitoring liver and kidney function  \n• PrEP reduces the risk of contracting HIV by approx . 99%  \nPrEP Coverage Requirements  \n• Affordable Care Act requires non-grandfathered individual and small group plans to cover ten Essential Health Benefits (EHB), including preventive services with no cost-sharing  \n• June 2019: U.S . Preventive Services Task Force (USPSTF) issues \"A\" rating for PrEP for certain at-risk populations  \n• January 2021: All EHB plans must cover PrEP w/o costsharing  \nState Actions  \nCompliance beginning January 2020  \nFurther Bulletin encouraging coverage of ancillary services w/o cost-sharing  \nFederal Actions  \n• Not included on [healthcare.gov](healthcare.gov) list of preventive services  \n• Some plans link to this list  \n• PrEP ancillary services should also be covered w/o cost-sharing – example-colonoscopies  \n• Interim Final Rule issued in December 2020 reiterates this  \n• FAQ on PrEP Pending  \n2021 Plan Review  \n• Spot check of formularies during Open Enrollment Period (Nov. 2020)  \n• Many plans in compliance  \n• Offering at least 1 PrEP Rx w/o cost-sharing  \n• But several not & transparency issues  \n• Redid Spot Check (March 2021)  \n• Greater compliance, some transparency improvements, but still some violations  \nCareSource-Georgia  \nOscar 2021 Formulary  \nExamples of Plan Violations  \n\n|  | Medical Mutual (OH) | ConnectiCare (CT) | Kaiser Permanente (GA) |\n| --- | --- | --- | --- |\n| Truvada: | Tier 4 | Tier 4 (notes\u003Cbr>Generic Available) | Not listed |\n| Descovy: | Tier 4 | Tier 4 | Tier 5 |\n| Generic: | Not listed |  | Tier 2 (Preferred Generic) |\n| Preventive Drugs: | Tier 5 | Tier 0\u003Cbr>Separate Document listing allACARx, PrEP not included | ACA |\n| Formulary Updated: | 3/1/2021 | 3/1/2021 | 3/10/2021 |\n\nTransparency Issues  \n• Kaiser Permanente (WA & DC): Tier 4 for all 3 Rx, but should be Tier P  \n• Separate Document Listing Preventive Drugs, PrEP included  \n• Many plans place on high tiers, but then if you click for additional information, $0 cost sharing  \n• Lack of Consistency for Preventive Rx: Tier 0, Tier 1, Tier 5, Tier 7, Tier P, $0,“Prev”, or “ACA”","cbCail8UpZcK3eHm","https://ap.wps.com/l/cbCail8UpZcK3eHm","pdf",499891,13,"English","# What is PrEP?\n# PrEP Coverage Requirements\n# State Actions\n# Federal Actions\n# 2021 Plan Review\n## Examples of Plan Violations\n## Transparency Issues","[{\"question\":\"What is PrEP and how is it taken?\",\"answer\":\"PrEP is pre-exposure prophylaxis for HIV prevention. It is an FDA-approved, once-daily medication regimen with required follow-up visits and periodic lab monitoring.\"},{\"question\":\"What insurance rules require PrEP coverage without patient cost-sharing?\",\"answer\":\"The Affordable Care Act requires non-grandfathered individual and small-group plans to cover Essential Health Benefits, including preventive services, with no cost-sharing. In January 2021, all EHB plans must cover PrEP without cost-sharing.\"},{\"question\":\"What issues were found during the 2021 plan review?\",\"answer\":\"The review included spot checks of formularies during Open Enrollment. While many plans complied and offered at least one PrEP prescription without cost-sharing, some plans were not compliant and had transparency problems.\"}]","Schmid-HealthHIV-PrEP-Insurance-Coverage-March-2021 | PDF",1790548229,33]