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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


ADAP MM 2020-20
June 16, 2020


TO:
PREP-AP ENROLLMENT WORKERS

SUBJECT:
PREP-AP ELIGIBILITY REQUIREMENT CHANGE FOR INSURED PREP-AP CLIENTS

​ADAP MANAGEMENT MEMO 2020-20: PREP-AP ELIGIBILITY REQUIREMENT CHANGE FOR INSURED PREP-AP CLIENTS


The purpose of this Management Memorandum is to notify PrEP-AP enrollment workers of the U.S. Preventative Services Task Force (USPSTF) recommendation to require health plans to cover Pre-Exposure Prophylaxis (PrEP) as a preventative service and a change in the requirement for insured PrEP-AP clients to enroll into Gilead’s Copayment Assistance Program.

Background

On June 11, 2019, the U.S. Preventative Services Task Force (USPSTF) recommended health plans to cover PrEP for persons at high risk of HIV acquisition. Per the Federal Code of Regulations, Section § 2590.715-2713 (b)(1) Coverage of preventive health services, health plans are expected to implement the USPSTF recommendation one year after the date the recommendation or guideline is issued. Thus, June 11, 2020, health plans are expected to cover the cost of PrEP for persons identified as high risk for contracting HIV. For more information on USPSTF’s recommendation, please refer to the Final Recommendation Statement issued by the USPSTF at the link below. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis.

Updated PrEP-AP Policy for Insured clients

Insured PrEP-AP clients were previously required to enroll into Gilead’s Copayment Assistance Program to receive co-pay assistance with Truvada and Descovy as many health plans did not cover PrEP as a preventative service. In response to USPSTF’s recommendation, the PrEP-AP will be changing its policy and will not require clients to enroll into Gilead’s Copayment Assistance Program as the client’s health plan will cover the cost of PrEP effective June 11, 2020, unless the health plan has yet to implement USPSTF’s recommendation. If the client’s health plan has yet to implement USPSTF’s recommendation, the client will be required to enroll into Gilead’s Copayment Assistance Program.

Below you will find a partial list of health plans that have implemented or will implement USPSTF’s recommendation and their associated go live date. If a client is enrolled in a health plan not listed below, please have the client contact their health plan to find out if they cover PrEP without cost sharing.

• Blue Shield of California- Renewing group plans will have this benefit added as of July 1, 2020. Clients with individual and family plans will have this benefit added effective January 1, 2021.

• Kaiser Permanente- Go live July 1, 2020, with $0 cost share for Affordable Care Act compliant plans, which includes both Covered CA and individual and family off exchange plans.

• Health Net- As individual members or groups re-new health coverage after 6/11/20, this benefit will be added. All members should have this added benefit by January 1, 2021.

Please Note: PrEP-AP will continue to cover PrEP-related medical out of pocket costs for clients with insurance, along with the approved medications listed on the PrEP-AP formulary. In addition, clients enrolled in Medicare without prescription drug coverage are still required to enroll into Gilead’s Patient Assistance Program and PrEP-AP every 12 months. Clients enrolled in a Medicare Part D plan are still required to enroll in PrEP-AP every 12 months, but are not required to enroll into Gilead’s Patient Assistance Program as they are not eligible.

If you have any questions regarding the contents of this Management Memorandum, please email the PrEP-AP inbox at PrEPSupport@cdph.ca.gov.


Thank you,

Chris_Unzueta_E_Signature.jpg

Chris Unzueta,

Operations Eligibility Section Chief

California Department of Public Health



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