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Commissioner Lara issues Notice to take action in reducing HIV transmission and ensure health insurance companies cover HIV PrEP without patient cost sharing

News: 2020 Press Release

For Release: June 10, 2020
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Lara issues Notice to take action in reducing HIV transmission and ensure health insurance companies cover HIV PrEP without patient cost sharing
Commissioner Lara’s formal action to expand access to PrEP seen as integral part of California’s “Getting to Zero” Plan to end HIV in the state

LOS ANGELES, Calif. — Today Insurance Commissioner Ricardo Lara issued a Notice to all disability insurance companies providing health insurance coverage in California informing them that their obligation to provide preventive health services coverage for HIV preexposure prophylaxis (PrEP) without cost sharing for patients begins tomorrow, June 11.

“Californians taking proactive steps to stay healthy and protect themselves from HIV should not face barriers to access and treatment,” said Insurance Commissioner Ricardo Lara. "Especially in this moment with the coronavirus pandemic exposing the inequality in our health system like the AIDS crisis did three decades ago for the LGBTQ community, we cannot allow for more HIV infections to occur when we can effectively prevent them. This new requirement for covering PrEP and the essential medical services needed to stay on PrEP without cost sharing will help reduce transmission of HIV and get us closer to our goal of ending the HIV epidemic, including in communities of color, among young adults, and in the transgender community.”

Commissioner Lara’s Notice describes the requirements for covering PrEP, following last year’s grade “A” recommendation from the U.S. Preventive Services Task Force (USPSTF) that individuals at high risk of contracting HIV must be offered PrEP medication, inclusive of lab and clinic visits, by their health care provider. Provisions in the federal Affordable Care Act and the California Insurance Code require most private insurance plans and Medicaid expansion programs, which includes Medi-Cal, to cover all USPSTF grade “A” and “B” rated services and medications with no cost sharing for patients, including deductibles, copayments, and coinsurance.

According to the U.S. Centers for Disease Control and Prevention, more than 1 million Americans could benefit from PrEP, but less than 25 percent are actually using the medication. Increasing PrEP use is a key component of the federal government’s plan to reduce new HIV infections by 90 percent by 2030. In 2018, there were 136,566 Californians living with diagnosed HIV infection and 4,747 Californians were newly diagnosed with HIV infection with the highest rate of new infections in the African American and Latinx communities. Public and private insurance coverage for PrEP correlates with increased utilization and adherence among those who are prescribed PrEP. 

Commissioner Lara’s Notice explains that, under California law, PrEP and the medical services necessary for prescribing and ongoing adherence to PrEP that are recommended by the U.S. Centers for Disease Control and Prevention, must be covered in-network without a deductible, copayment, or coinsurance. Insurance companies also cannot require prior authorization or step therapy for patients to access PrEP drugs.

Commissioner Lara further states in the Notice that disability insurance companies providing health insurance coverage in California can contribute to slowing the HIV epidemic by covering PrEP without cost sharing for all their policyholders beginning on the June 11th anniversary of the USPSTF recommendation, rather than waiting until policies renew. In addition, the Notice reminds insurance companies that they must not cover prescription drugs for treating HIV in a discriminatory manner by subjecting all or most drugs to high cost sharing or utilization management restrictions that are not grounded in evidence-based practices.

“No one should have to worry about whether they can afford their copays for HIV prevention medication, especially right now when many Californians are facing significant financial challenges due to COVID-19,” said Craig E. Thompson, CEO of APLA Health. “Today’s Notice from the Department of Insurance is a critical step toward eliminating financial barriers and increasing PrEP uptake in California. APLA Health is grateful to Commissioner Lara for taking swift action to implement the USPSTF recommendation to make PrEP affordable for all Californians. We echo the Commissioner’s call on insurers to implement the notice for all policyholders this week and help further the state’s goal of ending the HIV epidemic.”

“San Francisco AIDS Foundation applauds Commissioner Lara’s quick work to implement the USPSTF’s recommendation that health insurance plans make PrEP affordable,” said Joe Hollendoner, CEO of San Francisco AIDS Foundation. “PrEP has been proven to be a highly effective intervention in preventing new cases of HIV, and this action is an important step towards increased access for all Californians. We urge the Department of Managed Health Care to follow suit. We know, however, that access does not automatically result in utilization so we also call on healthcare providers to do everything they can to build awareness and earn the trust of community members who are at-risk for HIV acquisition—especially those who are Black, Indigenous and other people of color—about PrEP and how it can protect their sexual health.”

"New HIV infections continue to disproportionately impact communities of color, making PrEP awareness, access, and affordability an urgent priority," said Dr. Ward Carpenter, Co-Director, Health Services of the Los Angeles LGBT Center. “We commend Commissioner Lara and the California Department of Insurance for taking these steps to increase the use of PrEP throughout California. Eliminating financial barriers and stigma while increasing accessibility will help people, including those most at-risk, stop the spread of HIV.”

"In light of the current health and economic crises, it's more important than ever that Californians have access to life-saving HIV prevention medication," said Equality California Executive Director Rick Chavez Zbur. "This action will help ensure no Californian is forced to choose between paying for PrEP and putting food on the table or paying their rent. We're grateful to Commissioner Lara for his leadership in the fight to end the HIV epidemic."

On June 20, 2019, Commissioner Lara issued a Notice advising all insurance companies and fraternal benefit societies licensed to sell life, disability income, or long-term care insurance in California that, under state law, a person’s history of PrEP use cannot be used as a justification to deny life, disability, or long-term care insurance coverage or charge higher premiums for that coverage. This Notice encouraged insurance companies to review their underwriting guidelines and practices to ensure they are not unlawfully discriminating against applicants seeking insurance coverage. A number of insurance companies have reported back to the Department of Insurance that they have since discontinued these discriminatory practices.


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Media Notes:

Led by Insurance Commissioner Ricardo Lara, the California Department of Insurance is the consumer protection agency for the nation's largest insurance marketplace and safeguards all of the state’s consumers by fairly regulating the insurance industry. Under the Commissioner’s direction, the Department uses its authority to protect Californians from insurance rates that are excessive, inadequate, or unfairly discriminatory, oversee insurer solvency to pay claims, set standards for agents and broker licensing, perform market conduct reviews of insurance companies, resolve consumer complaints, and investigate and prosecute insurance fraud. Consumers are urged to call 1-800-927-4357 with any questions or contact us at via webform or online chat. Non-media inquiries should be directed to the Consumer Hotline at 800-927-4357. Teletypewriter (TTY), please dial 800-482-4833.

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