The new year brought a new requirement: most private health plans must now cover the full cost of expensive HIV-prevention drugs.
But when you read most, you know that means not all. So how can you find out if your plan will pick up the tab?
Step One: Learn about your plan formulary
A formulary lists all of the medications – both brand name and generic – covered by a health plan.
Health plans sometimes share their formulary online. Or you can usually request it from a human resources department.
Understanding your formulary might save you money when working with your doctor to choose any prescription drug.
For example, do you know drugs fall into different tiers? Tiers help define who pays for the medication and how much.
Tier 1 tends to include lower-cost generic drugs. Higher tiers generally list higher-cost brand-name drugs.
Higher tier medications often come with more cost sharing. That means the insured person must pay part of the price. That payment usually comes as a deductible, coinsurance or copayment.
Step Two: Search for the drug names
Brand name PrEP drugs are Truvada and Descovy. There is only one generic PrEP drug available in the United States.
One key thing to know – Truvada and Descovy also treat HIV. To find out whether your plan covers them when prescribed for HIV prevention, contact your insurer directly and ask.
Plans are only required to cover one of the drugs in the category without cost-sharing. You may need to get approval from your insurance provider if you use a drug that’s not on the plan’s formulary.
The CDC offers guidance on deciding whether PrEP therapy is right for you.
Have Health Insurance Questions?A licensed insurance agent can help you find the coverage right for you. Call 24/7: