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July 2020
Blue Cross and BCN will cover Truvada for HIV PrEP, starting in July
Effective July 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will cover HIV medication Truvada® for pre-exposure prophylaxis with no cost share for most commercial members at high risk for HIV.
A generic version of Truvada is expected to be released in September 2020. At that time, only the generic version will be covered with no cost share. The cost for brand Truvada will depend on the member’s benefit.
Truvada and Descovy® are the only two drugs indicated for HIV PrEP. If a member is newly prescribed Descovy for PrEP on or after May 1, 2020, we won’t cover the prescription unless prior authorization criteria are met. In such situations, prescribers should submit a prior authorization request. Otherwise, the prescription claim won’t be covered at the pharmacy.
We’ll only approve a prior authorization for Descovy for PrEP if there is documentation of a creatinine clearance (CrCl) less than 60 mL/min or osteoporosis.
Truvada and Descovy both contain tenofovir and emtricitabine. Each tenofovir component is formulated as a pro-drug.
Differences in pro-drug formulation and subsequent half-life don’t affect efficacy but can influence side effect profiles. Descovy demonstrated non-inferiority to Truvada in the DISCOVER trial, which means both drugs are equally effective in preventing the transmission of HIV-1.
Both drugs are contraindicated as PrEP in patients with unknown or positive HIV status. Using Descovy or Truvada for PrEP without confirmation of negative HIV status may increase the risk of developing HIV-1 resistance substitutions.
For members using Descovy to treat HIV, their normal cost share will apply.
Which members can receive this at $0 cost share?
This medication will be covered at $0 cost share for Blue Cross and BCN commercial members who are at high risk of contracting HIV. We’ll cover generic Truvada for PrEP at $0 cost share when it’s available.
This change doesn’t apply to grandfathered employees, retirees or groups with religious accommodation exceptions.
Why are we doing this?
The U.S. Preventive Services Task Force has recommended that:
- Providers offer PrEP with effective antiretroviral therapy to patients at high risk for HIV.
- It must be offered with no cost share.
The Centers for Disease Control and Prevention reports that PrEP is highly effective for preventing HIV. Studies have shown that it reduces the risk of contracting HIV through sexual transmission by about 99% when taken daily. Among people who inject drugs, PrEP reduces the risk of getting HIV by at least 74% when taken daily. PrEP is much less effective if it isn’t taken consistently.
What is the USPSTF recommendation?
The following is the draft recommendation summary:
| Population |
Recommendation |
Grade |
| People at high risk of HIV acquisition |
The USPSTF recommends that clinicians offer pre-exposure prophylaxis with effective antiretroviral therapy to people who are at high risk of HIV acquisition. |
A |
A grade of A or B means it must be offered as preventive at $0 cost share.
Who can prescribe PrEP?
Any licensed prescriber can prescribe PrEP. Specialization in infectious diseases or HIV medicine isn’t required. In fact, primary care providers who routinely see people at risk for HIV acquisition should consider offering PrEP to all eligible members. |
