Under the Affordable Care Act (ACA), preventive services with an A rating from the U.S. Preventive Services Task Force must be covered by health plans without patient cost sharing, including PrEP medications. Starting January 2021, most health plans were required to offer PrEP to their beneficiaries without copays. The objective of this study was to monitor time trends in total and out-of-pocket (OOP) payments for PrEP medications before and after implementation of the ACA requirement for no cost sharing.
We analyzed IQVIA Real World Data-Longitudinal Prescriptions Database to identify PrEP prescriptions using a validated algorithm. We estimated mean total and OOP payment per 30 PrEP tablets from January 2019 through March 2021, stratified by payer type and drug type. Payer type included commercial insurance, Medicaid, Medicare, cash payment, Gilead medication/copay assistance programs, and the federal Ready, Set, PrEP program. The three types of drugs currently available for PrEP are brand tenofovir disoproxil fumarate/emtricitabine (F/TDF), brand tenofovir alafenamide/emtricitabine (F/TAF; since October 2019), and generic F/TDF (since October 2020).
We identified 2,216,789 PrEP prescriptions with complete payment data (71% of all PrEP prescriptions). In 2019, 95% of the PrEP tablets prescribed were F/TDF, and 5% F/TAF. The proportion of F/TAF tablets prescribed increased since 2019 to 40% in 2020, and 47% in Q1 2021. The proportion of generic F/TDF tablets prescribed increased from 7% in 2020 to 35% in Q1 2021. The mean OOP payment per 30 tablets for generic F/TDF was $13 in 2020, and $10 in Q1 2021. As a result, mean total payments per 30 tablets for PrEP drugs decreased from $1,687 in 2020 to $1,581 in January-March 2021 due to more use of generic PrEP. When stratified by payer type, the mean OOP payment per 30 tablets among those with commercial insurance decreased from $108 in 2019 to $97 in Q1 2020. Mean OOP payment per 30 tablets among cash payers decreased from $1,762 in 2019 to $1,346 in Q1 2021 (Table).
We observed only a modest decreasing trend in OOP payments for PrEP in Q1 2021; and the decrease was largely due to persons with commercial insurance and cash payers. The ACA provision for no patient cost sharing can increase access to PrEP by removing financial barriers. Ongoing monitoring of trends in PrEP drug payments is important to understand impact of the ACA policy as the proportion of persons in grandfathered, exempt plans decreases.