QUESTION

I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but my insurance plan will not cover the medication my doctor prescribed without cost sharing. Is this allowed?

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

It depends. PrEP is a recommended preventive service, and ACA plans must cover it without cost sharing. However, federal guidance allows plans to require use of generic or preferred brand drugs for PrEP unless there is a medical reason to access the non-preferred brand name drug. In that case, you are entitled to the medically appropriate non-preferred brand name drug without cost sharing. If you think your medication was denied inappropriately, you can appeal this decision starting with the internal appeals procedure your insurer must provide you. (CMS, Affordable Care Act Implementation FAQ – Part 47, July 19 2021).

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