1. Craig Pulsipher, MPP, MSW State Affairs Specialist
PrEP Cost Analysis for Covered California Health Plans
Craig Pulsipher, MPP, MSW
State Affairs Specialist

2. Health Insurance and PrEP
Study of 504
HIV-negative
MSM
220,000 to 240,000 Californians with indication for PrEP
72.4%
had health insurance
MSM
Insured
6.1% insured through Covered California
Minimum of 9,000 people currently taking PrEP in California
PrEP is an important part of our prevention toolkit; yet financing to secure access to PrEP for individuals at high risk for HIV infection remains challenging. OA estimates that there are 220,000 to 240,000 Californians with an indication for PrEP, including 104, ,000 MSM. Data from multiple sources, including Medi-Cal, the Los Angeles County Comprehensive HIV Plan ( ), and multiple sources in San Francisco, suggest that a minimum of 9,000 people are currently taking PrEP in California.
2015 study of you gay and bisexual men found that 72.4% had health insurance, 6.1% through Covered CA.
Given restrictions with regard to use of federal funding from CDC and HRSA’s Ryan White Program to pay for medications for HIV negative individuals, leveraging other payers and health care systems is crucial to expanding access to PrEP, particularly for vulnerable populations—and assisting PrEP candidates secure the best possible health plan coverage for PrEP is one of the strongest tools that we have at hand right now to boost PrEP access.
So given the gaps in categorical funding and the increased access to health insurance that we have seen since the implementation of the Affordable Care Act (ACA), assistance in navigating coverage options and choosing plans that are affordable and comprehensive will remain a strategic priority in facilitating access to PrEP.
Covered CA
California Needs Assessment for HIV. California Department of Public Health, Office of AIDS. September 2016.
Pulsipher CA, Montoya JA, Plant A, Curtis P, Holloway IW, Leibowitz AA. Addressing PrEP Disparities among Young Gay and Bisexual Men in California. September 2016.

3. Covered California Analysis
Estimating the annual cost of “being on PrEP” to the patient across Covered California health plans
Information needed to calculate costs
Premium
Drug copay (requires knowledge of drug tier)
Doctor copay
Laboratory copay
Deductibles
Out-of-pocket maximum
All information available online
2017 Standard Benefit Plan Designs
Shop and Compare tool
Health plan formularies

4. Calculating PrEP Costs
Premium – based on age, region, income, metal level
Drug costs – approximately $1,250 before deductible, then copays after deductible
Doctor visits – months 1, 2, 5, 8, 11 (5 visits); approximately $200 before deductible
Laboratory tests – months 1, 2, 5, 8, 11 (5 visits)
Deductibles – sometimes separate medical and pharmacy
Out-of-pocket maximum
Premium based on: your age (the older you are, the more expensive health insurance is); your region (typically, if you live in Northern California you will pay more for health insurance than if you live in Southern California); •our income (given that you can get premium assistance if your income is less than or equal to 400% FPL, as described above); the metal level you choose (you will pay the highest premiums for Platinum level, followed by Gold, then Silver, then Bronze).

5. Factoring in Copay Assistance
Gilead’s Truvada copay assistance program provides up to $3,600 annually, with no monthly cap

7. 25 year-old with annual income of $17,820 (150% FPL) in Los Angeles

8. AUTHORS
AJ King, MPH
Craig A. Pulsipher, MPP, MSW
Ian W. Holloway, MSW, MPH, PhD
FUNDER
This study was funded by the California HIV/AIDS Research Program (Grant Number RP15–LA–007).
ACKNOWLEDGMENTS
This study was conducted by the California HIV/AIDS Policy Research Center at UCLA/APLA Health, through a generous grant from the University of California HIV/AIDS Research Program. Additional support was provided by the Center for HIV Identification, Prevention, and Treatment Services NIMH grant P30MH We thank Jennifer Gildner and Sean Beougher for their assistance with fact checking and copyediting. We also wish to thank Sneha Patil from the San Francisco Department of Public Health, for her valuable input.

9. Craig Pulsipher, MPP, MSW
State Affairs Specialist, Government Affairs
APLA Health
direct
fax