Government Mandates Health Plans To Cover $25,000 Drug

Government mandate forces health plans to cover Truvada, the only FDA approved drug used to prevent HIV. Annual cost of this drug is $25,000…………………

Influential panel urges HIV prevention drug, forcing payer hands

Samantha Liss

PUBLISHED June 12, 2019

Dive Brief:

  • The influential US. Preventive Services Task Force recommends people at high risk of HIV take Gilead Sciences’ Truvada, which can prevent the disease. The Affordable Care Act mandated commercial plans to cover a certain set of preventative services, including those that get an A or B from the task force.
  • The expert advisory group found “convincing evidence” that PrEP, or preexposure prophylaxis, provides a “substantial benefit” when it comes to decreasing the risk of HIV.
  • The task force assigns a letter grade to each of its recommendations based on medical evidence and the treatment’s potential benefits. USPSTF does take into account cost of a treatment in its recommendation decision. The task force assigned an A to the HIV prevention treatment.

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Dive Insight:

The recommendation could potentially expand access to PrEP as the task force’s endorsement carries weight and requires many insurers to cover the prescription at no cost to the patient, according to an expert at the Kaiser Family Foundation.

Adoption of PrEP is not widespread among those who stand to benefit the most, according to the Centers for Disease Control and Prevention. About 1 million could take PrEP, but only 90,000 prescriptions were filled in 2015, according to the CDC. The FDA approved PrEP for HIV prevention in 2012.

Numerous barriers contribute to the low uptake, including the stigma surrounding HIV and AIDS and the estimated $20,000 annual price tag of the drug.

“We know that there are really significant access issues to PrEP right now,” Lindsey Dawson, assistant director for HIV policy at KFF, told Healthcare Dive.

Truvada is the only FDA approved drug used to prevent HIV. Its patent protection runs out in 2020, though the company has another PrEP drug in the pipeline, Descovy. Truvada generated sales of nearly $3 billion in 2018, according to Gilead’s annual SEC filing.

The company has faced backlash for Truvada’s price-tag, about $1,780 per month, according to Biopharma Dive.

Though the action is a significant step forward, Dawson noted important distinctions in the recommendation.

The task force’s recommendation is geared toward covering the drug regimen and not the ancillary services associated with obtaining a PrEP prescription, including lab work, doctors visits and the costs associated with those visits.