Consumers reminded about PrEP coverage under Affordable Care Act

In observance of HIV/AIDS Awareness Month and to further the Shapiro Administration's commitment to Pennsylvanians' wellbeing, the Pennsylvania Insurance Department (PID) and the Department of Health (DOH) today remind Pennsylvanians of the importance of HIV pre-exposure prophylaxis (PrEP) medication for HIV prevention.

The Affordable Care Act (ACA) requires that HIV PrEP be covered at zero cost-sharing for insured consumers, expanding access to the life-changing medication.

"We want to remind consumers that the federal government requires most insurers to cover HIV PrEP medication at zero out-of-pocket cost to the consumer if the consumer is at high risk of HIV acquisition," said Pennsylvania Insurance Commissioner Michael Humphreys. "Nobody should ever forgo medically necessary preventive medication or services because of cost, and PID is committed to ensuring that all health insurance plans under its jurisdiction are following the requirements to cover PrEP and related services with no cost sharing."

In 2025, Pennsylvanians who have an increased risk of HIV acquisition and are enrolled in individual and small group plans will have coverage – with no cost sharing – for HIV PrEP medication, integral services necessary to start PrEP and all ongoing follow-ups. The Department recently released a report – the first of its kind in Pennsylvania – that highlights integral services covered by health plans including:

An interaction with a provider for a prescription (up to 90-day supply) or injection;

Adherence and behavioral risk reduction counseling;

Medication management generally, and medication management with long-acting injectable PrEP;

Tele-PrEP;

Pregnancy testing as part of a doctor's appointment for PrEP;

HIV screening;

Hepatitis B virus screening and testing;

Hepatitis C virus screening;

Renal function testing;

Gonorrhea, chlamydia, and syphilis screening; and

Triglyceride and cholesterol level monitoring.

No cost sharing means that the consumer will not be charged an out-of-pocket copayment, deductible or coinsurance for these drugs. Tests, doctor visits and other services directly related to obtaining PrEP and included in the PrEP billing should also be covered with no out-of-pocket cost to the consumer.

"Not only can people with HIV live long and healthy lives with proper treatment, but medications like HIV PrEP can also prevent the spread of HIV and keep people healthy," said Secretary of Health Dr. Debra Bogen. "We want Pennsylvanians to know that medical prescription costs should not deter them from getting the care they need. The Department of Health, through the Special Pharmaceutical Benefits Program, helps residents with medication costs to stay on track with treatment for HIV and other illnesses."

Pennsylvanians who received HIV PrEP medication and were charged a copayment, coinsurance, or deductible should contact their health insurer to request a refund. The number for the insurer can usually be found on the back of the health insurance card. Additionally, Pennsylvanians with questions about their insurance or coverage of HIV PrEP medication, or who need to submit a complaint, may contact PID's Consumer Services Bureau online or by calling 1-877-881-6388. Consumers looking to learn more about health insurance should visit PID's website and Health Insurance page.

Anyone who doesn't have health coverage can join the over 430,000 Pennsylvanians who have found a quality health plan at the lowest costs through Pennie, the commonwealth's official online health insurance marketplace. Pennie's open enrollment period is the only opportunity for Pennsylvanians to find affordable, high-quality health plans for coverage that begins in 2025. Pennie's Open Enrollment Period runs through January 15, 2025, with December 15 marking the deadline for coverage beginning January 1, 2025. For those enrolling between December 16 and January 15, coverage will begin February 1, 2025.

Nine out of 10 Pennie customers qualify for financial savings in the form of tax credits to help reduce monthly premium payments. Many customers also qualify for financial assistance to lower out of pocket costs. All health plans offered through Pennie cover essential services like hospital care, mental health support, prescriptions, maternity care and more.

Pennsylvanians looking for health coverage through Pennie can visit pennie.com or call Pennie's customer service at 844-844-8040. Pennie's Customer Service Center is open during open enrollment from 8 a.m. to 7 p.m., Monday through Friday, and on Saturday from 8 am to 1 p.m.

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