QUESTION

I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but I received a bill for cost sharing for the labs I needed to start the medication. Is this allowed?

Post enrollment issues | Individual Health Insurance Employer-Sponsored Coverage
ANSWER

No, not under an ACA plan. PrEP is a recommended preventive service and must be covered without cost sharing. This includes coverage of the medication, the medical visit, and the essential support services (HIV testing, STD testing, hepatitis testing, kidney function testing, and adherence counseling), all without cost sharing. You can appeal this claim starting with the internal appeals procedure your insurer must provide you. Federal guidance currently requires insurers to cover all required labs for PrEP without cost sharing. (CMS, Affordable Care Act Implementation FAQ – Part 47, July 19 2021).

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