Insurance Company Prior Authorization Could Block Access to HIV Meds, PrEP

The Affordable Care Act And HIV PrEP

Despite provisions in the Affordable Care Act (ACA) restricting insurance providers from discriminating against patients with pre-existing conditions like HIV, insurance companies continue to employ “utilization management” (UM) protocols like prior authorization to block patients trying to prevent HIV infection from accessing prophylactic care.

Brooklyn Community Pride Center Executive Director Floyd Rumohr

Prior to the ACA (also known as Obamacare) private insurers regularly denied coverage for people with pre-existing disabilities like HIV, or charged them ridiculously high premiums. The ACA banned this practice and prohibited insurers from providing health benefits in a way that would discourage people with HIV from enrolling in the insurer’s health plan.

Insurance companies have responded by using indirect UM methods—like prior authorization requirements and exorbitant prescription co-pays—to block access to medications used to prevent the spread of HIV, which have become among the most expensive drugs in some health plan formularies. 

In July, United Healthcare, one of the nation’s largest health insurers, notified members that it would require all patients seeking anti-retroviral drugs for pre-exposure prophylaxis (PrEP) to obtain prior authorization for the medications every three months. Prior authorization requires a patient’s physician to complete a form and provide any additional information the insurer requests to determine why the patient needs the medication and whether a prescription is medically necessary. 

Shortly after United announced its new prior authorization requirements, it sent a letter denying coverage for PrEP to a gay man in New York City on the basis that he was engaging in “high risk homosexual behavior.” Ironically, the letter specified that PrEP is only covered in specific situations, including “to reduce the risk of sexually-acquired HIV-1 infection in adults at high risk.”

The resulting uproar—involving ACT UP NYC and a request for New York’s health commissioner to investigate United—compelled the health insurer to reverse its position on prior authorization and issue a public letter of apology to the man. 

As a cost-saving strategy, denying PrEP to anyone engaging in high-risk behavior is foolishly short-sited. According to the Center for Disease Control, PrEP is over 92 percent effective at preventing HIV infection among the 1.2 million adults the CDC believes are at risk. It costs the insurer much less to cover PrEP for members likely to contract HIV than to pay for a lifetime of anti-retroviral therapy and HIV/AIDS treatment.

Trying to save a buck by increasing the barriers patients must overcome to access anti-retroviral treatments mostly likely runs afoul of the ACA’s prohibitions against discriminatory treatment coverage. In fact, while the Centers for Medicare and Medicaid Services (CMS) have not explicitly barred prior authorization for HIV medications, it has identified “requiring prior authorization…for most or all medications in drug classes such as anti-HIV protease inhibitors” as design features that “might be discriminatory.”

Tougher access to PrEP may be one reason that Brooklyn neighborhoods Bedford-Stuyvesant and Crown Heights now report the highest rates of new HIV infection in New York City. Large immigrant populations without access to consistent health care, combined with a number of clinic closings, have made it difficult for residents in these neighborhoods to even know if they are HIV positive, let alone seek treatment. The last thing at-risk individuals in these neighborhoods need is more barriers to access medications that could prevent infection.

Health insurance companies are supposed to facilitate essential healthcare, not stand in its way. It should not take a public scandal for insurers to see that requiring prior authorization for PrEP is not in their own financial interest, nor in the long-term interest of New Yorkers. All of New York’s health insurance providers to learn from United’s blunder, and cover PrEP for any patients whose doctor prescribes it.

Floyd Rumohr is Executive Director of the Brooklyn Community Pride Center.


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