CurrentColorado Rocky Mountain Health PlansPolicy N/A

HIV Pre-exposure Prophylaxis (PrEP) medications zero dollar cost share

Rules for zero dollar cost-share coverage of specified PrEP medications (Descovy, generic tenofovir fumarate, brand Truvada, and brand Viread) including authorization duration and conditions; applies to the payer's pharmacy clinical programs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHIV Pre-exposure Prophylaxis (PrEP) medications zero dollar cost share

Policy CodePolicy N/A

Change TypeAdded brand Truvada and Viread coverage (11/2024)

Effective Date3/1/2026

Next Review Date

Key ActionRequest authorization attesting PrEP is preventive and, if brand requested, that generic is medically inappropriate to obtain zero dollar cost share for 12 months.

SourceLink

POLICY UPDATE CHANGES

Added Descovy strength indicated for PrEP.

Updated program name to specify 'Fully Insured'.

Updated criteria with no change to clinical intent.

Added coverage for brand Truvada and brand Viread.

Annual review with no changes noted.

12 monthsauth duration

Descovy, generic tenofovir, Truvada, Vireadmedications included

2020-2025P&T history

Zero Dollar Cost Share Coverage Criteria

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Descovy or generic tenofovir (zero dollar cost share)

Covered at zero dollar cost share when the following are met:

Zero-dollar coverage for Descovy or generic tenofovir: 1. Preventive care coverage for pre-exposure prophylaxis (PrEP) is being requested

Authorization will be issued for zero copay with deductible bypass for 12 months. If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Brand Truvada (zero dollar cost share)

Covered at zero dollar cost share for brand Truvada when ALL of the following are met:

Brand Truvada zero-dollar coverage: 1. Preventive care coverage for pre-exposure prophylaxis (PrEP) is being requested

AND 2. Provider attests use of generic Truvada (emtricitabine/tenofovir disoproxil fumarate) is medically inappropriate. Authorization will be issued for zero copay with deductible bypass for 12 months. If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Brand Viread (zero dollar cost share)

Covered at zero dollar cost share for brand Viread when ALL of the following are met:

Brand Viread zero-dollar coverage: 1. Preventive care coverage for pre-exposure prophylaxis (PrEP) is being requested

AND 2. Provider attests use of generic Viread (tenofovir disoproxil fumarate) is medically inappropriate. Authorization will be issued for zero copay with deductible bypass for 12 months. If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Approvals for PrEP medications at zero dollar cost share may be granted using administrative data alone when appropriate. UnitedHealthcare may approve initial requests and reauthorizations based solely on previous claim or medication history, relevant diagnosis codes (ICD-10), and/or internal claim logic. Automated approval and re‑approval processes vary by program and therapeutic class, so fulfillment can occur without additional clinical documentation when these program rules are satisfied.

Provider Requirements and Actions

Prior Authorization

Zero dollar cost share authorization (12 months)

Zero dollar cost share authorization (12 months) — Authorization for zero copay with deductible bypass will be issued for 12 months when preventive PrEP coverage is requested for the listed medications. If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Applies to Descovy (200/25 mg), tenofovir 300 mg, brand Truvada (200/300 mg), and brand Viread (300 mg).
Authorization term: 12 months; if criteria are unmet drug defaults to standard plan coverage.

Documentation Required

Brand coverage requires generic contraindication attestation

Brand coverage requires generic contraindication attestation — To obtain zero dollar cost share for brand Truvada or brand Viread, the provider must attest that the corresponding generic (emtricitabine/tenofovir disoproxil fumarate for Truvada; tenofovir disoproxil fumarate for Viread) is medically inappropriate.

Required when requesting zero dollar cost share for brand Truvada (200/300 mg): provider attests generic Truvada is medically inappropriate.
Required when requesting zero dollar cost share for brand Viread (300 mg): provider attests generic Viread is medically inappropriate.

Documentation Required

Provider attestation for brand preference

Provider attestation for brand preference — When requesting zero dollar cost share the provider must attest that use of the generic medication (Truvada or Viread) is medically inappropriate and that preventive PrEP is being requested.

Preventive PrEP indication must be documented.
Provider must specify clinical rationale why generic product is medically inappropriate for this patient.

Billing Rule

Default to standard coverage if criteria unmet

Default to standard coverage if criteria unmet — If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Standard plan coverage (including applicable copay and deductible) will apply when attestations or preventive PrEP indication are not provided or insufficient.

Initial Zero Dollar Cost Share Criteria

Initial zero dollar cost share

Initial zero dollar cost share approval

Initial approval for Descovy or generic tenofovir: Preventive care PrEP is requested; authorization will be issued for zero copay with deductible bypass for 12 months

If zero dollar cost share criteria are not met the requested drug will default to standard plan coverage.

Step	Requirement	Coverage Label
1	Provider attests that use of the corresponding generic product (generic Truvada or generic Viread) is medically inappropriate.	Zero-dollar cost share for brand product requires attestation

Definitions

PrEP — Pre-exposure prophylaxis (PrEP) definition and related items

TermPre-exposure prophylaxis (PrEP)

PurposeUse of effective antiretroviral therapy to reduce risk of HIV acquisition in persons at increased risk

Medications included for zero dollar cost shareDescovy 200/25 mg; tenofovir fumarate 300 mg (generic); Truvada (emtricitabine/tenofovir disoproxil fumarate) — brand; Viread (tenofovir disoproxil fumarate) — brand

Authorization duration for zero dollar coverageAuthorization issued for 12 months when preventive PrEP coverage is requested

Brand product requirementProvider must attest that the generic equivalent is medically inappropriate to obtain zero dollar cost share for brand Truvada or brand Viread

Background and Clinical Rationale

The U.S. Preventive Services Task Force (USPSTF) recommends clinicians prescribe pre‑exposure prophylaxis (PrEP) — effective antiretroviral therapy — to persons at increased risk of HIV acquisition to reduce HIV incidence. Consistent with this recommendation and federal health care reform requirements, the payer provides zero dollar cost‑share coverage for specified PrEP medications when the policy criteria are met; authorization for zero copay with deductible bypass is issued for 12 months when preventive PrEP coverage is requested for the listed products.