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Prep Cost Analysis for Covered California Health Plans (English)

January 9, 2017

PrEP is a highly effective medication for preventing HIV. Those interested in PrEP and enrolling in a Covered California health plan should carefully weigh the costs of a Truvada® prescription, copays for regular doctors’ visits and laboratory tests, and monthly premiums. With Gilead’s copay card, PrEP is affordable (less than $400/year) on all Covered California health plans except Bronze plans. However, this does not include the cost of monthly premiums and assumes that medical and pharmacy deductibles have not been met. You can use Covered California’s shop and compare tool to see the cost of premiums in your area at CoveredCA.com/shopandcompare. Certified Enrollment Counselors and Insurance Agents, as well as Covered California call center representatives are also available to answer questions about financial assistance and help you compare plans. You can find free, in-person help at CoveredCA.com/get-help. Before you make any final decisions be sure that the primary care doctor you are considering takes the plan you want and is willing to prescribe PrEP.

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PrEP Cost Analysis for Covered California Health Plans

What is PrEP?

PrEP stands for pre-exposure prophylaxis. It is a medication that HIVnegative people can take to prevent them from getting HIV. When taken every day it is up to 99% effective. Truvada® is currently the only medication that is approved for PrEP in the United States. More information about PrEP can be found at PrepFacts.org.

What is Covered California?

Covered California is the state’s health insurance marketplace where qualified, lawfully present residents of California can purchase affordable health insurance. You can enroll in a Covered California health plan during annual open enrollment between November 1, 2016 and January 31, 2017. You can also enroll at any time during the year if you experience a life-changing event such as getting married, having a child, or moving. You can enroll online at CoveredCA.com.

How does Covered California work?

All Covered California health plans have standard benefits including prescription drug coverage, doctors’ visits, hospitalization, labs, and mental health and substance abuse services. Covered California health plans are available in four metal levels: Bronze, Silver, Gold and Platinum. As the metal level increases in value (from Bronze to Platinum), so does the percentage of medical expenses that the health plan covers relative to what you are expected to pay in copays and deductibles. Plans in higher metal levels have higher monthly premiums, but you pay less when you need medical care. If you choose a plan with lower monthly premiums, then you will pay more when you need medical care.

In addition to the metal level you choose, your health care costs will depend on your age, where you live, your household size, and your household income. If your income is equal to or less than 400% of the federal poverty level ($47,520), you can receive a tax credit that you may use to reduce your monthly premiums. In addition to the tax credit, if your income is equal to or less than 250% of the federal poverty level ($29,700), you may also qualify for assistance that lowers your out-of-pocket costs. This additional financial assistance is only available if you select a Silver plan and is known as an Enhanced Silver plan. There are three categories of Enhanced Silver – Silver 73, Silver 87 and Silver 94.

How much will PrEP cost me through Covered California?

The costs associated with PrEP through Covered California include your monthly premiums, copays for your Truvada® prescription, and copays for regular doctors’ visits and laboratory tests. It is also important to understand your deductibles and out-of-pocket maximum before enrolling in a new health plan. Gilead, the company that manufactures Truvada®, has a copay card that will pay up to $3,600 per year to help cover the cost of the medication. You can apply for the copay card online at GileadCoPay.com. The table on the reverse depicts the annual cost of PrEP by metal level with and without the Gilead copay card. In spring 2017, the California Department of Public Health, Office of AIDS will launch a PrEP financial assistance program to cover PrEP-related out-of-pocket costs for qualified individuals with annual incomes below 500% of the federal poverty level.

Glossary

Premium: The amount you pay every month for your health insurance plan.

Deductible: The amount you pay before the health plan begins to pay.

Copay: A fixed amount that you pay for services until you reach your out-of-pocket maximum.

Out-of-Pocket Maximum: The most you have to pay for medical expenses during the year above and beyond your monthly premiums.

Formulary: The list of prescription drugs covered by a health insurance plan.

Metal Level	Out-of-Pocket Maximum[1]	Medical Deductible[2]	Pharmacy Deductible[2]	Preferred Drug Copay3]	Primary Care Visit Copay[4]	Laboratory Test Copay	Estimated Annual PrEP Costs[5]	Estimated Annual PrEP Costs with Gilead Copay Card[5]
Bronce	$6,800	$6,300	$500	100% up to $500 per script	$75 (deductible applies after 1st three non-preventive visits	$40	$6,800	$3,200
Plata	$6,800	$2,500	$250	$55	$35	$35	$1,205	$350
Plata Mejorada 73	$5,700	$2,200	$250	$50	$30	$35	$1,125	$325
Plata Mejorada 87	$2,350	$650	$50	$20	$10	$15	$395	$125
Plata Mejorada 94	$2,350	$75	$0	$10	$5	$8	$185	$65
Gold	$6,750	$0	$0	$55	$30	$35	$985	$325
Platinum	$4,000	$0	$0	$15	$15	$20	$355	$175

Table: Summary of Estimated Annual PrEP Costs by Metal Level (not including premiums)
[1] PrEP costs may be less if out-of-pocket maximum is reached.
[2] Costs are calculated assuming medical and pharmacy deductibles have not been met.
[3] Truvada® is currently covered by all CMetal overed California health plans and is listed as a Tier 2, “preferred” drug. Drug formularies can change at any time, so always verify medication coverage directly with a health plan before enrolling.
[4] Out-of-pocket costs may be higher if you are required to see a specialist instead of a primary care doctor. Costs are calculated assuming the cost of a primary care visit is $200, but that amount may vary from plan to plan.
[5] Cost estimates include five doctor visits and five labs during the first year of PrEP initiation to account for the initial visit, a one-month follow-up visit, and then three additional follow-up visits every three months for the duration of the year. Cost estimates do not include the cost of monthly premiums.

Summary

PrEP is a highly effective medication for preventing HIV. Those interested in PrEP and enrolling in a Covered California health plan should carefully weigh the costs of a Truvada® prescription, copays for regular doctors’ visits and laboratory tests, and monthly premiums. With Gilead’s copay card, PrEP is affordable (less than $400/year) on all Covered California health plans except Bronze plans. However, this does not include the cost of monthly premiums and assumes that medical and pharmacy deductibles have not been met. For this reason, it is very important that you consider both outof- pocket costs and monthly premiums before you select a health plan. You can use Covered California’s shop and compare tool to see the cost of premiums in your area at CoveredCA. com/shopandcompare. Certified Enrollment Counselors and Insurance Agents, as well as Covered California call center representatives are also available to answer questions about financial assistance and help you compare plans. You can find free, in-person help at CoveredCA. com/get-help. Before you make any final decisions be sure that the primary care doctor you are considering takes the plan you want and is willing to prescribe PrEP. A list of doctors with experience providing PrEP can be found at PleasePrepMe.org.

To learn more visit CHPRC.org.

This study was conducted by the California HIV/AIDS Policy Research Center at UCLA/APLA Health, through a generous grant from the University of California HIV/AIDS Research Program. RESEARCH CENTERS