By Hunter W. Collins
On July 6, 2021, the Department of Managed Health Care (DMHC) released All Plan Letter (APL) 21-018, which requires health plans to provide “coverage for Human Immunodeficiency Virus (HIV) antiretroviral drugs, including preexposure prophylaxis (PrEP) or postexposure prophylaxis,” and includes guidance on “prior authorization and step therapy as well as preventative health services and cost sharing.” This APL followed previous APL 20-026, which dealt with preventive health services coverage for HIV PrEP. In that APL, released in 2020, DMHC directed health plans to cover preexposure prophylaxis, as well as follow-up treatment, with no cost sharing.
The current APL states that as of January 1, 2020, SB 159 (Wiener) (Chapter 532, Statutes of 2019), which added section 1342.74 to the California Health and Safety Code, prohibited commercial and Medi-Cal plans with prescription drug benefits from requiring prior authorization or step therapy for antiretroviral drugs that are medically necessary for the prevention of HIV, including preexposure prophylaxis or postexposure prophylaxis. [24:2 CRLR 29–30] If a therapeutic equivalent drug exists, then the plan must cover at least one of the versions without prior authorization or step therapy. Under federal mandate, all group or individual plans must cover preventive health services, without cost sharing, for HIV PrEP to any individual who is determined to be at high risk of contracting HIV by the attending health care provider.
According to the APL, by August 6, 2021, all plans must submit a compliance filing that affirms full compliance with SB 159, updated formularies to reflect these changes, as well as coverage for baseline and follow-up testing and monitoring for PrEP without any share of cost. As an alternative, the plan may explain why the requirements do not apply to their circumstances.