PrEP and PEP are Prevention Act
This bill requires private health insurance, Medicare, Medicaid, and federal employee plans to fully cover HIV prevention medications, including PrEP and PEP, with no out-of-pocket costs. Patients will pay zero copays, coinsurance, or deductibles for the drugs, as well as for associated doctor visits, lab testing, and prevention counseling. It also generally prohibits private health insurers from requiring prior authorization before covering these preventive medications, provided an equivalent covered drug is available without delay.
What this bill touches.
Who it helps · who it burdens.
Who it helps
- Enrollees in private group and individual health insurance plansGain full coverage for FDA-approved HIV prevention drugs (PrEP and PEP), laboratory testing, counseling, and clinical monitoring without any cost-sharing, along with protections against prior authorization requirements.
- Medicare beneficiariesReceive 100 percent coverage under Medicare Part B and complete elimination of deductibles, coinsurance, and cost-sharing under Medicare Part D for HIV prevention drugs and related clinical services.
- Medicaid and CHIP enrolleesGain guaranteed coverage for HIV prevention drugs, diagnostic procedures, counseling, and monitoring without copayments or other cost-sharing.
- Federal employees and dependents enrolled in FEHB plansReceive complete coverage without cost-sharing for HIV prevention drugs, administrative fees, testing, counseling, and clinical monitoring under FEHB plans.
Who it burdens
- Private health insurance issuers and group health plansRequired to provide first-dollar coverage for HIV prevention drugs and associated clinical services without charging cost-sharing, and prohibited from imposing prior authorization unless a therapeutically equivalent alternative is covered without prior authorization.
- State Medicaid and CHIP agenciesMandated to cover comprehensive HIV prevention services and drugs in standard and benchmark Medicaid and CHIP coverage without imposing any cost-sharing on participants.
- Federal Employees Health Benefits (FEHB) carriersRequired to include benefits for HIV prevention drugs, diagnostic testing, counseling, and monitoring with zero cost-sharing across all offered plans.
The provisions, in plain language.
Requires private group and individual health insurance plans to cover FDA-approved HIV prevention drugs—including PrEP and PEP—as well as associated lab tests, counseling, and clinical monitoring without charging any cost-sharing, starting the first plan year after enactment.
Prohibits private health insurance plans from requiring prior authorization for HIV prevention services, except for a specific drug if an equivalent alternative drug is covered without prior authorization.
Expands Medicare Part B to cover HIV prevention drugs, diagnostic tests, counseling, and clinical monitoring at 100 percent payment, exempting patients from the Part B deductible and coinsurance, starting January 1 of the first year after enactment.
Eliminates all deductibles, coinsurance, and cost-sharing for HIV prevention drugs under Medicare Part D prescription drug plans, including for low-income subsidy recipients, starting the first plan year after enactment.
Requires state Medicaid programs and benchmark health plans to cover HIV prevention drugs, lab testing, counseling, and follow-up services without imposing any cost-sharing on patients.
Requires Children’s Health Insurance Program (CHIP) plans to cover HIV prevention drugs and related clinical services for low-income children and pregnant individuals without cost-sharing.
Requires Federal Employees Health Benefits plans to provide full coverage for HIV prevention drugs, administrative fees, testing, counseling, and monitoring without any cost-sharing, starting the first plan year after enactment.