Removing Barriers to PrEP in Massachusetts
PrEP is a simple, safe, and effective medication that reduces the risk of HIV transmission by close to 100% and provides our best opportunity to end the HIV epidemic.
An Act to address barriers to HIV prevention medication (SB 619/HB 1085) prohibits insurers from imposing cost sharing or utilization review (also referred to as utilization management), such as prior authorization or step therapy, for PrEP medication.
The Affordable Care Act requires commercial insurers and Medicaid expansion programs to cover without cost sharing (e.g., co-pays, deductibles) select preventive services given a Grade A recommendation by the United States Preventive Services Task Force (USPSTF). In June 2019 the USPSTF gave PrEP an “A” rating which was updated in December 2022 to cover new PrEP medications, including long-acting injectable medication. A robust body of medical literature demonstrates that cost-sharing substantially reduces access to medical care, especially prevention.
A lawsuit brought by plaintiffs who are hostile to the ACA specifically challenging the USPSTF’s PrEP recommendation threatens this critical federal cost-sharing prohibition. In September 2022 a federal district judge in Texas ruled that the members of the USPSTF are unconstitutionally appointed. Braidwood Management, Inc. v. Becerra, United States District Court for the District of Texas (No. 4:20- cv-00283, September 7, 2022). The judge’s further order implementing his decision is expected in the first quarter of 2023.
Even now, Massachusetts insurers are not doing a good job complying with the existing federal mandate, with rejected claims and billing errors leading patients to stop taking PrEP (Boston Globe). Make no mistake, HIV transmission will increase if insurers are legally allowed to impose cost sharing for PrEP. Massachusetts must act.
In addition, the advent of long-acting injectable medication brings us into a new era in the quest to end the HIV epidemic. Studies have demonstrated that long-acting injectable medication is more effective at preventing HIV transmission than daily oral medication because of better adherence for people who cannot be compliant with a daily pill regimen. A long-acting injectable medication can also be administered immediately in a clinical setting, syringe access program, or other mobile site. Studies have shown that utilization review has generally been associated with delayed or denied access to care; and PrEP cannot be administered in any of these innovative settings if healthcare providers must first obtain prior authorization from an insurer.
The bill is sponsored by Senator Julian Cyr and Representative Jack Lewis.