In September, Dr. Robert Grant, HIV prevention researcher and professor at UCSF’s Gladstone Institute, estimated that if 6,000 San Franciscans at high risk infection took Truvada, the number of new infections annually in the city might drop from 400 to 50.
But for individuals — and the city at large — to benefit from the 90-percent effectiveness rate of Truvada when taken daily, people have to be able to afford it. And one of the big barriers to that is simply understanding health insurance. A 2014 Kaiser Family Foundation survey found that 18 percent of people who buy their own insurance didn’t know their monthly premium. Another 37 percent didn’t what their deductible was, and that’s to say nothing of the cost of prescriptions.
But to afford Truvada, you have to weigh all these factors, said Matt Sachs, San Francisco’s only official PrEP navigator. So, he said, start by checking the following on every plan you’re considering:
- Your premium: That is, how much you pay a month.
- Your deductible: This is how much you must pay out of pocket before your benefits kick in. On Covered California, the lowest-premium plans also come with a $5,000 deductible.
- Your prescription benefits: On plans with the lowest premiums under Covered California, you’re also likely to have a deductible for prescriptions in addition to a deductible for appointments and lab work.
(These tips also apply to anyone in the market for health insurance.)
The best bet for a plan that will cover Truvada? Sachs told The Daily Beast that Covered California "silver-tier" plans, are usually the best bet. You’ll pay more out of pocket every month for your premium than you would for a bronze plan, but silver plans have lower deductibles — only $250 — and copays of $50.
Since the regimen for Truvada includes quarterly doctors’ appointments and lab work to test for HIV, sexually transmitted infections, and liver and kidney function, a silver-level plan may cost you less in the long run, said Brad Hare, director of HIV Care and Prevention at Kaiser Permanente San Francisco.
“Just like you have to talk about the side effects of drugs and safer sex, with Truvada, we also have to talk about the cost of the drug,” he said.
If you are planning to keep the same Covered California plan, that doesn’t mean your benefits will stay the same year over year. Hare and Scott both said they advise patients to investigate their current plans before the end of open enrollment, since many plans are changing radically in terms of the benefits they provide, and cost-sharing they require.
“Covered California is new,” he said. “There are going to be a lot of changes to Covered California plans in the next few years. So it’s really important, if people aren’t changing plans, to look every year and to be mindful of what your pharmaceutical benefits are.”
But even if you investigate your plan thoroughly, you may be hit with a surprise, as Erik Gibb was when he went to pick up his three-month supply of Truvada in January. Gibb did not buy through Covered California, he purchased a plan directly from Kaiser San Francisco, a plan with a high premium, but no deductible and low copays for prescriptions — all so he could afford PrEP.
But at the pharmacy, he discovered that the cost of the drugs has radically changed in 2015 — from a $15 copay to more than $400, the result of a formulary change that switched Truvada and other specialty drugs from payment on a copay basis to coinsurance, where patients pay a percentage of the cost of the drug. And Gibb is not alone. When San Francisco AIDS Foundation and Project Inform created an analysis of where HIV drugs like Truvada fall on various Covered California-plan formularies, they found unpredictable changes, Courtney Mulhern-Pearson with the AIDS Foundation told The Daily Beast.
Kaiser's Hare confirmed the change, saying the company’s pharmacy department made the change, affecting at least all Kaiser's California facilities and potentially all of them nationwide. While the change doesn’t affect every Kaiser insurance plan, it does affect every plan the company offers on Covered California and some direct-purchase individual plans. The change means coinsurance costs of between 10 and 40 percent.
For his part, Gibb doesn’t like the switch, but at least for him, it doesn’t put Truvada out of reach.
“Don't get me wrong, I don't like paying that at all,” he said. “And I would love it if Kaiser would integrate with the reimbursement program like other pharmacies, but I can deal.”
The cost change is a concern from Hare’s end, as well. His department is contacting PrEP patients who might be at risk of cost changes to warn them. He said he directs them to Kaiser’s internal medical financial assistance program.
There’s also a medication assistance program from Gilead, which covers the full cost of the drug for a limited time for people who earn less than $58,000 a year, as well as a Gilead copay assistance card, which covers $300 a month toward the cost of the prescription. Last month, the Patient Access Network (PAN) Foundation also announced that it will cover Truvada for PrEP in its drug assistance program.