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Paying for PrEP

couple at computerPrEP is an important tool for preventing HIV. However, it's fairly common to face issues getting insurance and prescription plans to pay for PrEP. Following is information about your insurance rights and expansive resources and tools for getting on PrEP and getting it paid for.

DO YOU KNOW YOUR PrEP INSURANCE RIGHTS?

Did you know that most private health plans must cover PrEP at zero costs to you? In 2021, the US government issued guidelines that most private health plans and Medicaid expansion plans must cover PrEP because the United States Preventive Services Task Force (USPSTF) gave PrEP a Grade A recommendation. For you, this means that you are required to pay ZERO co-pays, co-insurance, or deductibles for your:

  • Medication,
  • PrEP provider visits,
  • Labs,
  • HIV & STI screenings,
  • Adherence counseling, and
  • Pregnancy tests. 

WHAT RESOURCES DO I NEED TO GET ON PrEP AND GET IT COVERED?

The resources below identify ways to pay for PrEP (including the requirement for zero-cost co-pays), resources to help consumers advocate for their rights, and billing guides for providers to ensure paperwork is coded correctly so insurance plans approve and cover PrEP costs. 

Read about the USPSTF recommendations and learn how to advocate for yourself and your PrEP!

STILL BEING CHARGED FOR PrEP?

PrEP and associated services are required to be covered by law, but not every provider and insurance company is up to speed. If you are still having issues getting PrEP paid for or if you received a bill for PrEP services, you should bring the federal guidance to the attention of your health plan. If that doesn’t work, you can also contact federal and state regulators to file a coverage complaint. Refer to the Patient Advocacy Toolkit resource above for more information. You can also report non-compliance and help inform our advocacy efforts by submitting the form at this link.

Consumer & Patient Resources

Resources to help you get on PrEP, stay on PrEP, and to make sure its paid for by insurance at no cost to you. 

Know Your Rights Handout

A guide for what patients need to know about new Federal Guidelines on Coverage of PrEP with No Cost-Sharing

View Resource

Patient Advocacy Toolkit

A guide for patients to ensure plans comply with USPSTF patient protections for PrEP

View Resource

USPSTF - PrEP FAQs 

Frequently Asked Questions (FAQs) regarding implementation of PrEP from USPSTF

View Resource

Covering the Costs of PrEP and PEP

A resource page from PleasePrEPMe for covering the cost of PrEP and PEP

View Resource

Covering Costs of PrEP Job Aid

Tips and Resources for Covering Costs of HIV PrEP from HealthHIV

View Resource

PrEP Discussion Guide

A companion discussion guide from USPSTF to facilitate meaningful discussions between clinicians and their patients.

View Resource

State Level Department of Insurance Guide

Links to state-by-state Dept. of Insurance consumer complaint websites

View Resource
man at computer
Frontline & Clinical Provider Resources

A collection of resources designed to support providers as they help their PrEP patients navigate the insurance landscape.

Ensuring Compliance with New Federal USPSTF PrEP Guidance

A Quick Take topic brief on the federal PrEP guidance

View Resource

State Level Department of Insurance Guide

Links to state-by-state Dept. of Insurance consumer complaint websites

View Resource

Billing Coding Guide for HIV Prevention: PrEP, Screening, and Linkage Services

A resource guide from NASTAD to assist in navigating billing and reimbursement for HIV prevention services.

View Resource

ICD-10 Code Lookup Tool

A quick lookup tool from the Centers for Medicare & Medicaid for finding billing codes pertinent to PrEP coverage

View Resource

Medical Coding Clinic, Clearinghouse, and Inquiries

A tool from Coding Clinic Advisor through which specific coding questions may be submitted 

View the Resource

ICD-10-CM Codes (Outpatient and Clinical Billing Codes)

A list of all ICD-10-CM codes used in clinical and outpatient settings in the U.S.

View Resource

ICD-10-PCS Codes (Inpatient and Hospital Billing Codes)

A list of all ICD-10-PCS codes used in inpatient and hospital settings in the U.S.

View Resource
doctor

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STILL BEING CHARGED FOR PrEP?

PrEP and associated services are required to be covered by law, but not every provider and insurance company is up to speed. If you are still having issues getting PrEP paid for or if you received a bill for PrEP services, you should bring the federal guidance to the attention of your health plan. If that doesn’t work, you can also contact federal and state regulators to file a coverage complaint. Refer to the Patient Advocacy Toolkit resource above for more information. You can also report non-compliance and help inform our advocacy efforts by submitting the form at this link.

 

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This resource page was developed with support from Gilead Sciences. The information was developed solely by HealthHIV.