September 09, 2022

Warren Joins Merkley, Smith in Sounding Alarm on Unlawful Charges for PrEP Patients

AHIP members reported to unlawfully charge patients for necessary medications and ancillary services that are critical to preventing HIV infection

 Text of Letter (pdf) 

Washington, D.C. – Today, United States Senator Elizabeth Warren (D-Mass.) joined Senator Jeff Merkley (D-Ore.), Tina Smith (D-Minn.), Chris Van Hollen (D-Md.), Bernie Sanders (I-Vt.), Tammy Baldwin (D-Wisc.), Edward J. Markey (D-Mass.), and Cory Booker (D-N.J.) in a letter to AHIP, the trade association representing health insurance companies, expressing concern about unlawfully charging individuals for pre-exposure prophylaxis (PrEP) medication and related care.

The Senators' letter follows a Wednesday court ruling that further threatens affordable access to PrEP. As the legal process moves forward, the Senators pressed the health insurance industry to abide by current law to provide medication and ancillary services without charge.

“It has been brought to our attention that enrollees in your members’ health plans continue to be charged for necessary medications and ancillary services—including provider consultations and laboratory services—contrary to law and additional federal guidance issued by the Departments of Labor, Health and Human Services, and Treasury,” wrote the Senators. “We write to express our deep concern with these erroneous and unlawful charges, and to request additional information on steps that AHIP is taking to ensure that its members adhere to federal law and ensure the PrEP drugs and the full scope of PrEP ancillary services are offered without charge to enrollees.”

A 2019 ruling by the U.S. Preventive Services Task Force (USPSTF) gave PrEP an “A” rating as prevention intervention for people at risk of Human Immunodeficiency Virus (HIV) and under the Public Health Service Act insurance coverage is required for services or interventions.  The Centers for Medicare & Medicaid Services (CMS) issued guidance in July 2021 that further clarified the USPSTF ruling. Noting that “plans and issuers must cover PrEP consistent with the USPSTF recommendation without cost sharing,” the ruling goes on to clarify that PrEP is not just the medication, but also all of its necessary related services including testing, screening, and provider visits. Despite this ruling and subsequent clarification, individuals are still being wrongly charged out-of-pocket expenses relating to their PrEP care.

“In light of this clear guidance from CMS, we are alarmed by continual reports that patients are routinely billed, either for payment-in-full or for cost-sharing practices, related to medically-appropriate medications and essential services,” they continued. “These costs can be daunting. HIV advocates and clinical workers across the county have reported that many patients are unaware that they do not have to pay out-of-pocket for PrEP and ancillary services, assuming that many of these costs are simply necessary for being on PrEP medication.”

The Senators’ letter highlights the inequities in PrEP uptake across communities at higher risk for HIV—including Black and Hispanic communities and transgender women—due to limited access to financial resources needed to cover costs of PrEP and associated medical visits and laboratory tests, among other factors.

In light of these concerns, the lawmakers ask clarifying questions and request a response from AHIP within 30 days.