Guide to Getting PrEP with or without Insurance Coverage
PrEP is one of the most recent advancements in anti-HIV medication. PrEP is a daily pill that if taken as directed can be 99% effective in reducing your risk of contracting HIV.
With such incredible benefits, it is common for people to wonder whether PrEP is covered by insurance and how to get PrEP if you are uninsured. Luckily, PrEP is covered by most major insurance plans, including Medicare and Medicaid. Learn more about how to get PrEP without insurance, and how to get assistance even if you have insurance.
Have Insurance? It’s Possible to Get PrEP Covered by Insurance
If you have insurance, PrEP is often fully covered by most major insurance plans and it is worth asking your insurance company about.
People often search for getting PrEP without insurance even if they have insurance coverage, because they believe that their insurance plan will not cover the cost or the copay will be too high. The good news is this is often not the case. However, if you find out that your insurance plan’s copay is too high to make PrEP affordable or free, Gilead, the biopharmaceutical company responsible for branding the PrEP medication Truvada, offers payment assistance through its Gilead Advancing Access program. This program can help:
- Cover the cost of copays - Gilead has a Copay Coupon Program that covers up to $300 of copay, so any copay that this $300 or less means PrEP will be free.
- Find an insurance plan that does cover PrEP - Gilead can also help answer questions about which insurance plans do cover PrEP in case you wanted to switch, and they will work with you to see what are feasible options.
- Appeal a denial from an insurance claim – Gilead can work with your healthcare provider to appeal an insurance claim that gets denied for PrEP coverage.
Getting PrEP with Medicare, Medicaid, or Medi-Cal
There are many government insurance programs to help make PrEP affordable or free for you. Both Medicaid and Medicare fully cover PrEP, but at varying copays.
- Some states are beginning to work with the AIDS Drug Assistance Program to assist in the covering the cost, including New York, Washington State, and Washington, D.C.
- San Francisco has a wealth of support services, including the San Francisco City Clinic and the city’s healthcare access program that covers PrEP, Healthy San Francisco.
There are other patient assistance programs from foundations or agencies that can help you find resources to cover the cost, or even help cover the cost.
- PleasePrepMe.org has a virtual chat where navigators are available to answer your questions anonymously and to help find PrEP providers that take your insurance. Simply visit the homepage and click the chat bubble icon on the left side of the page.
- PrEPLocator.org can help you find a provider near you who takes your insurance, or who has the ability to help those who are uninsured via free visits or PrEP navigation.
- Partnership for Prescription Assistance is a free service that helps connect you with assistance programs and is especially useful for people who are on government insurance plans and are looking for copay assistance.
- Patient Advocate Foundation (PAF) can help those who have health insurance (including government-sponsored health insurance) and the medication is covered. It is possible to qualify for access to $7500 per year to pay for associated costs. Persons making less than 400% of the federal poverty line (or about $47,500) may qualify for this program (pending income verification) to help cover the costs of copays, deductibles, and coinsurance.
- Patient Access Network (PAN) Foundation can help those who have health insurance (including government-sponsored health insurance) and the medication is covered. It is possible to qualify for access to $7500 per year to pay for associated costs. Anyone making less 500% federal poverty line (or about $58,800) may qualify for this program (pending income verification) to help cover the costs of copays, deductibles, and coinsurance.
Getting PrEP without Insurance
If you do not have insurance, you can still get PrEP. Gilead offers financial support for the uninsured through their Patient Assistance Program. If your financial situation qualifies, PrEP is free of charge. To be eligible for the program, you need:
- A doctor or healthcare provider willing to prescribe PrEP
- A negative HIV test within 90 days of the prescription
- Proof of income (tax return, W-2, pay stubs, etc.) that is under 500% of the poverty line for your area
- Proof of US residency (utility bill, bank statement, etc.)
The first step is to get a prescription from a healthcare provider. The second step is enrollment either by mail or online. Gilead offers trained counselors who provide weekday support over the phone for any questions you have. Once approved, you will have six months of PrEP daily doses mailed to your door or your pharmacy for pickup. You can renew every six months as long as you have a recent negative HIV test on file.
Getting a PrEP Prescription
You do NOT have to speak with an HIV specialist, though some general practitioners still are not aware of PrEP. If your doctor does not know about PrEP and is uncomfortable with writing you a prescription for it, try an online PrEP provider, or ask them for a referral to another doctor or specialist who can provide you with a prescription.
Other options you should consider:
- Check to see if your city has a local LGBT center. Centers often have a list of LGBT-friendly providers who may have more knowledge and experience with PrEP.
- Look up any local AIDS service organizations in your city as they may be able to help you find a provider.
If your provider does not know about PrEP but would like to learn more, have them contact the National Clinician’s Consultation Center or refer them to the CDC’s guidelines for prescribing PrEP and CDC PrEP Fact Sheet.
PlushCare offers expert health care, including PrEP, with one simple video chat on your phone. Our team of experienced doctors can provide diagnosis, treatment, and prescriptions over the phone. If you would like to get tested for HIV/AIDS or want to get started with PrEP, book an appointment with a PrEP-trained doctor today (simply indicate "PrEP" in the appointment notes).
Other Common Questions about HIV & PrEP
HIV stands for both the disease and the virus known as human immunodeficiency virus. When the virus enters the human body, it attacks a certain type of white blood cell known as the CD4 cell, which is also known as a T cell. The CD4 cell normally helps to eliminate invading bacteria, viruses, and other microorganisms. However, HIV infects and destroys these CD4 cells, using them to reproduce, grow, and spread further into your system. As the virus neutralizes your CD4 cells, your immune system begins to break down, and your body becomes unable to defend itself from other bacterial or viral infections.
What is PrEP?
PrEP is an abbreviation for pre-exposure prophylaxis. This is an anti-HIV medication intended for adults who do not have HIV but may be at a high risk of getting infected. The medication actually combines two HIV medicines, emtricitabine and tenofivir, into one pill that is sold under the brand name Truvada in the U.S.
PrEP works by interfering with the virus’s ability to create copies of itself in your body, thereby preventing HIV from replicating and spreading. PrEP must be taken once a day to work properly. When administered properly, PrEP has been shown to reduce the risk of contracting HIV through sex by 99 percent. It can reduce the risk of contracting HIV from using injected drugs by over 70 percent. PrEP can also be combined with other medications and protective strategies for further risk reduction.
Many people mistake PrEP as a type of vaccine, but it works differently. Vaccines use weakened or killed forms of certain microorganisms to teach white blood cells how to fight off the actual, full-powered microbes.
Who Should Take PrEP?
PrEP is designed specifically for people who are HIV-negative but have a high risk of infection, such as:
- Anyone who has a HIV-positive partner
- Anyone who is not in a mutually monogamous relationship and has recently tested negative for HIV
- Anyone who do not regularly use condoms while having sex with partners of unknown HIV status or at a high risk of HIV infection
- People who have used injected drugs in the last 6 months and shared needles
If your partner is HIV-positive and you and your partner are both considering having a baby, PrEP can also be used as a tool to protect you and your baby from contracting HIV during sex, pregnancy, and breastfeeding.
That said, PrEP is not for everyone. It requires you to take a pill every day to maintain protection and effectiveness, which means forgetting to take the pill is out of the question. PrEP also requires regular visits to your doctor, which may be difficult if you have already have a hectic schedule.
PrEP is also not intended for people who have HIV or may have been recently exposed to HIV. Those who suspect they have been exposed to the virus in the last 72 hours should consider taking PEP (post-exposure prophylaxis), which involves taking antiretroviral medication to prevent an infection after potentially being exposed to the virus via sex or injected drug use. PEP must be started within 72 hours after the initial potential infection.