My PrEP Experience is pleased to launch a new informational resource called "Truvada Track - monitoring insurance and Medicaid coverage of Truvada for PrEP."
This page - accessible via tab at the top of this blog - monitors insurance and Medicaid coverage of Truvada as PrEP . It will be updated frequently. The most current update is always at the top. If you have information about insurance of Medicaid coverage of Truvada for PrEP - including pre-authorization requirements or denials - please share this information with us by sending an email to myprepexperience@gmail.com.
Here is our first update.
• United Healthcare (commercial insurance): Prior authorization required, consistent with indication on label, triggered when Truvada is prescribed without a third agent or in the absence of code for HIV infection (see pictures above)
Questions, concerns, or clarifications - send email to myprepexperience@gmail.com
Here is our first update.
July 1, 2013 update
 |
| Letter from United Healthcare regarding pre-authorization requirements for Truvada as PrEP. |
 |
| Pre-authorization requirements for Truvada as PrEP from United Healthcare. |
• Aetna (commercial insurance): Prior authorization required, consistent with indication on label, triggered when Truvada is prescribed without a third agent or in the absence of code for HIV infection
• Florida Medicaid: Prior authorization required, consistent with indication on label, triggered when Truvada is prescribed without a third agent or in the absence of code for HIV infection
• New York Medicaid: Prior authorization requires documented HIV- test result; triggered when Truvada is prescribed without a third agent or in the absence of code for HIV infection
• Catamaran (pharmacy benefit management – select clients only): As of 6/25/13 – reports from health care providers of prior authorization impacting new starts on Truvada to confirm diagnosis (treatment vs. PrEP). Appears to allow PrEP use when consistent with label.
Notes:
- Up to July 1, we have not heard of denials of coverage. But pre-authorization requirements, many of which are just starting on July 1, could potentially lead to denial of coverage for Truvada as PrEP.
- "Without a third agent" - Truvada is a combination of 2 drugs, and appropriate treatment for people living with HIV consists of 3 or more drugs. So, when Truvada is prescribed and a third "agent" is not, this signals that Truvada is being prescribed as PrEP.
- United Healthcare is the largest insurer in the U.S., and we understand that approximately 300 of their members (out of a total in the millions) are currently taking Truvada without a third agent. A very, very small percentage of HIV-negative people for whom they provide insurance.
Questions, concerns, or clarifications - send email to myprepexperience@gmail.com
I am typing this as a frustrated United Healthcare member. For the last 8 months I have been taking Truvada. I am in a relationship in which my partner has been diagnosed as HIV positive. Although he is extremely healthy otherwise and undetectable, Truvada was an important regiment for me. Recently UHC and OptumRx initiated a prior authorization requirement from my doctor. My doctor requested the medication on my behalf twice, and both times have been turned down. The first time was July 2013 and second was this month, August 2013. Each time Optum/UHC never requested or asked for a prior auth form. In fact the second when the second denial came through the nurse called and spoke with "Jason" at Optum and he told her there is no such thing as a prior auth form for Truvada.
ReplyDeleteOn both denial letters it states "Truvada is denied. Authorization for therapy continuation requires the following: Your patient has no recent (less than 1 month) HIV exposures suspected. So, because MY test for HIV is currently negative I am not at risk? Your process is severely flawed. You do not provide the necessary information, or listen to the necessary information in order to determine coverage. "Jason" proceeded to ask the nurse at the doctors office a series of questions and then made his decision based on those verbal answers.
Hi R Smith
DeleteSorry you have experienced this. Wanted to let you know we were looking into it for you and will share any info/advice we gather.
Stay tuned. If you would prefer us to send a response to you directly via email, please email us at myprepexperience@gmail.com and we will respond to you that way.
Thanks for reaching out to us!