Mountain West AIDS Education and Training Center Pre-exposure Prophylaxis for HIV Prevention Cost and Access: Tips from the Field Joanne Stekler, MD MPH October 12, 2017 This presentation is intended for educational use only, and does not in any way constitute medical consultation or advice related to any specific patient.
Paying for PrEP Project Inform: www.projectinform.org
Case 1: Medicaid A 30 year old male patient asks about PrEP to reduce his risk of HIV acquisition. He uses methamphetamine daily and reports 50 male partners in the last 6 months for survival sex work. He is currently enrolled in your state Medicaid program. What do you tell him about his costs for PrEP? Medicaid should cover medical costs related to PrEP. If you encounter barriers to coverage, consult a legal advocate. ProTip: you may be required to complete prior authorizations for coverage.
Paying for PrEP Project Inform: www.projectinform.org
Case 2: Private Insurance Part 1 A 30 year old high-risk male patient asks about PrEP to reduce his risk of HIV acquisition. He has insurance through his employer. What do you tell him about his costs for PrEP? - His insurance *should* cover the costs of PrEP, though every plan is slightly different. - Run a test claim or ask the patient to call his insurance to ask regarding Truvada (Tenofovir 300mg/Emtricitabine 200mg) - His annual deductible - His monthly copays
Case 2: Private Insurance Part 2 He tells you that he has an annual deductible of $1500 and his monthly copay of 10%. What do you tell him about his costs for PrEP? - With the copay card (max $3600/calendar year), his medication will be covered $1500 + ($1500)(.1)(11) = $3150 - He will still have to cover the copay associated with provider visits and lab fees.
Paying for PrEP Project Inform: www.projectinform.org
Case 2: Private Insurance Part 3 Clinician visit costs Initial assessment CPT 99204 $166.73 Initial prescription CPT 99213 $73.30 Quarterly visit CPT 99213 $73.30 Annual follow-up CPT 99214 $108.88 Smith DK, JAIDS, 2017 Lab costs HIV Ab $36 HIV Ab/Ag $80 BMP $22 Urine pregnancy $17 HBV serology $28 RPR $12 NAAT GC/CT (site) $91 I did an informal survey of the PrEP FACTS group (biased) around out-of-pocket costs: 15 respondents, 1 largish ($1500) deductible meds/mo: median $0 (range $0-20) quarterly visits/labs: median $15 (range $0-65) But right after me, someone posted about costs of $5000/yr.
Case 2: Private Insurance Part 4 ProTips - His insurance may require him to use a mail order pharmacy, some of which are less willing to use the Gilead copay card as a secondary payer. - There are options both for fighting the mail order requirement as well as submitting copay receipts to Gilead for reimbursement. - Have pts take advantage of free or low cost HIV/STI testing at local CBOs - If sending large volumes of pts to a CBO, please consider supporting the CBO for the time/effort it takes to get all those ROI results to you!
Gilead Co-Pay Card: ProTips - Co-pay card is available to U.S. residents. - Someone can obtain co-pay assistance with - A physical card (needs to be activated) - Signing up online - Calling the assistance number - If using a pharmacy with not a lot of experience around PrEP, I give patients a physical card to hand to the pharmacist. - Copay assistance does not need a physician signature.
Case 3: The Uninsured A 30 year old high-risk male patient comes to you a month before Pride and asks about PrEP to reduce his risk of HIV acquisition. He works multiple part-time jobs, making about $2500/month, and has no work-provided healthcare insurance. What do you tell him about his costs for PrEP? - If his annual income is under 5x federal poverty level, he is eligible for the Gilead Medication Assistance Program - This form requires information and signature of the provider. - He will be required to cover the costs of visits and laboratory evaluations.
Paying for PrEP Project Inform: www.projectinform.org
Case 4: The Uninsured A 30 year old high-risk male patient comes to you in December and asks about PrEP to reduce his risk of HIV acquisition. He works multiple part-time jobs, making about $2500/month, and has no work-provided healthcare insurance. What do you tell him about his costs for PrEP?
Paying for PrEP Project Inform: www.projectinform.org
Gilead Medication Assistance Program: ProTips - It never hurts to call the assistance number to verify receipt of a MAP application. Some times applications may be incomplete, and they do not always inform you. - Every year, the program encourages people to sign up for health insurance through the exchange. To our knowledge, no one has been dropped from MAP coverage because they did not sign up during open enrollment. - If a client gets rejected initially, calling the MAP assistance number with additional information can often be helpful.
Case 5 Part 1: non-u.s. Citizens A 30 year old male patient asks about PrEP to reduce his risk of HIV acquisition. He is from Mexico and in the country illegally, working under the name and social security number of a relative. He is uninsured. What do you tell him about his costs for PrEP?
Case 5 Part 2: non-u.s. citizens 1) Verify that they are not eligible for expanded Medicaid 2) Submit an application to Gilead Medication Assistance Program - Accompany the application with a letter from a partner or relative that states: - I am writing this note to state that I assist [patient name] with food, clothing, and a place to stay, since they are not working and have no income at this time. - Letter may need to be notarized.
Case 6: Young Adults A 21 year old male patient who does not live in WA State asks about PrEP to reduce his risk of HIV acquisition. He has recently moved from California and has been going to the bathhouses every weekend. He is on his parents insurance but is not out to them and does not want them to know that he has sex with men. What do you tell him about his potential options for PrEP?
- Resources for young adults - www.myhealthmyinfo.org - PrEP/insurance navigators - Gilead Patient Insurance Assistance Other Resources - For patients who have insurance but are unsure whether our medicines will be covered by their insurance plan and therefore affordable, Gilead offers over-the-phone comprehensive case management and counseling services. When U.S. patients or their physicians call, our counselors help them understand what the patient s insurance will cover, residency requirements and other important but daunting details about the healthcare system. In 2014, we received calls from 21,956 physicians and 80,435 patients; 85 percent of them received insurance verification within two business days. - In Washington State PrEP DAP - If have someone who cannot otherwise get covered, contact WA DOH on case-by-case basis. - Soon to be sending out contracts to get PrEP prescribers able to bill PrEP DAP for visits and lab costs. Contact Lori Delaney (lori.delaney@doh.wa.gov) for more info!
ICD-10 codes to consider using for PrEP prescribing Visit and HIV/STD testing Z20 Z20.6 Z20.2 Contact with and (suspected) exposure to HIV Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Contact with and (suspected) exposure to other viral communicable diseases Z20.828 Z72.5 High risk behavior (main category not billable) Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z11 Z11.3 Z11.4 Encounter for screening infectious and parasitic diseases (not billable) Encounter for screening for infectious with a predominantly sexual mode of transmission Encounter for screening for HIV Laboratory monitoring Z51.81 Encounter for therapeutic drug level monitoring Z79.899 Other long-term (current) use of drug/prophylactic therapy Source: US Public Health Service. Clinical practice guidelines for PrEP. May 2014