Preventive HIV Pre-Exposure Prophylaxis (PrEP) Medications Coverage
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Defines AmeriHealth coverage for HIV pre-exposure prophylaxis (PrEP) medications provided as preventive care at no cost-sharing under the ACA/USPSTF recommendation; affects members using PrEP for HIV prevention.
No material clinical or coverage changes in this revision.
Coverage Criteria
Preventive coverage criteria
Covered at $0 when used for HIV prevention for members at increased risk.
Medications used for treatment of HIV infection are covered under the normal pharmacy benefit with usual cost-sharing.
Medications used for treatment of HIV infection are excluded from the $0 preventive benefit under this policy. When a listed product is prescribed for treatment of HIV infection rather than for prevention (pre-exposure prophylaxis), it will be processed under the member's normal pharmacy benefit and is subject to usual cost-sharing, including copayments, coinsurance, and deductible as applicable.
Provider Actions and Requirements
No prior authorization required for listed PrEP medications
No prior authorization is required for the PrEP medications listed as available at $0 when used for HIV prevention under this policy.
No step therapy requirements
The policy does not impose step therapy requirements for the listed PrEP medications.
Document PrEP indication for $0 preventive coverage
Document in the claim or medical record that the medication is being prescribed and used for HIV prevention (pre‑exposure prophylaxis) so the $0 preventive benefit applies.
- Indication must reflect use for HIV prevention (PrEP) rather than treatment of HIV infection.
$0 coverage only for PrEP (prevention) — treatment uses follow normal benefit
Coverage at $0 applies only when these medications are used for HIV prevention (PrEP); when used to treat HIV infection they are processed under the normal pharmacy benefit with usual member cost‑sharing.
- Ensure claims and documentation clearly indicate prevention vs treatment to avoid incorrect cost‑sharing.
- Medications listed as preventive are available at $0 for members using them for prevention.
Listed Preventive Products
Products listed as preventive
Listed products available at $0 for members using them for prevention.
Specific product selection may depend on clinical appropriateness and ability to take generics vs brand.
Definitions
Background
This coverage reflects the Patient Protection and Affordable Care Act requirement and the United States Preventive Services Task Force (USPSTF) recommendation that certain preventive medications for individuals at increased risk of HIV infection be provided without cost-sharing. Under this policy, HIV Pre-Exposure Prophylaxis (PrEP) medications are offered at $0 when used for prevention for members who are not infected but have an increased risk of acquiring HIV.
Providers should note that the $0 preventive coverage applies only when the medication is being used for PrEP; if the medication is used for treatment of HIV infection it will be covered under the standard pharmacy benefit with the member’s usual cost-sharing.
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