PrEP and PEP are Prevention Act
PrEP and PEP are Prevention Act would require no-cost coverage for HIV prevention services across several sectors of the U.S. health system. The bill expands the list of covered services to include FDA-approved HIV prevention drugs (notably PrEP and PEP), the administrative and laboratory work that accompanies those drugs, counseling on HIV prevention, and follow-up/monitoring in line with current public health guidelines. It applies to private insurance plans (through the Public Health Service Act), Medicare, Medicaid and CHIP, and the Federal Employees Health Benefits Program. It also bars preauthorization requirements for these HIV prevention services (with a narrow exception for a drug if there is no therapeutically equivalent option). In short, the bill makes PrEP/PEP and related prevention services free of cost-sharing across major health coverage programs to improve access and uptake. The bill defines “HIV prevention services” broadly to cover drugs for prevention (PrEP/PEP), related administrative and lab work, counseling, risk assessment, adherence support, and clinical follow-up. It sets specific effective dates tied to enactment (generally the first plan year or calendar year after enactment, with some state-law delay provisions for Medicaid/CHIP). The overall aim is to reduce financial and administrative barriers to HIV prevention and thereby reduce new HIV infections.
Key Points
- 1Private insurance: Expands no-cost coverage under the Public Health Service Act to include FDA-approved HIV prevention drugs (PrEP/PEP), related administrative/diagnostic services, HIV prevention counseling, and follow-up/monitoring, “without limitation” to services guided by USPHS clinical practice guidelines. It also prohibits most preauthorization requirements for these services, with a narrow exception for a drug if there’s no therapeutically equivalent option with preauthorization.
- 2Medicare: Adds HIV prevention services to Part B coverage and makes these services 100% covered (no coinsurance or deductible) for the prevention services defined in the bill. It also extends the Part D framework to eliminate cost-sharing for HIV prevention drugs, with related amendments to ensure consistent coverage of related services.
- 3Medicaid and CHIP: Requires inclusion of HIV prevention services (drugs for prevention, admin fees, labs, counseling, and follow-up) in Medicaid and CHIP coverage, with no cost-sharing for these services or drugs. It also adjusts benchmark and eligibility provisions to include these services, and provides an effective-date framework that allows for state plan approval delays if state law is required.
- 4Effective dates: Most amendments take effect the first plan year or first calendar year after enactment. Some provisions for Medicaid/CHIP allow a delay if a state requires additional legislation to implement the changes.
- 5Federal Employees Health Benefits Program (FEHBP): Requires FEHBP plans to cover HIV prevention drugs and related services with no cost-sharing, effective for the first plan year after enactment.
- 6Definition of HIV prevention services: The bill defines these consistently across programs as including FDA-approved preventive drugs (e.g., PrEP/PEP), administrative and lab costs, HIV prevention counseling, risk assessment/reduction, medication adherence support, and clinical follow-up in line with USPHS guidelines.