Starting May 1, 2020, we’ll change how we cover some drugs for HIV-1 PrEP

The U.S. Preventive Services Task Force has recommended that providers offer pre-exposure prophylaxis with effective antiretroviral therapy to people at high risk for HIV. The Centers for Disease Control and Prevention reports that when taken daily, PrEP is highly effective for preventing HIV-1.

In complying with this recommendation, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover Truvada^® and Descovy^®, the only two drugs indicated for HIV-1 pre-exposure prophylaxis. Members currently on Descovy won’t be affected by this change.

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 PA for Descovy for PrEP if there is documentation of:

• A creatinine clearance, or CrCl, <60 mL/min
• Osteoporosis 

Members using Descovy to treat HIV will receive their medication for their applicable copay.

Effective July 1, 2020, Blue Cross will cover Truvada for PrEP at $0 cost share for commercial members at high risk. We’ll cover generic Truvada for PrEP at $0 cost share when it is available.

Truvada and Descovy are very similar and both contain tenofovir and emtricitabine. Each tenofovir component is formulated as a prodrug. After administration, it’s metabolized within the body into an active drug.

Differences in prodrug formulation and subsequent half-life differences don’t affect efficacy but can affect side-effect profiles. Descovy demonstrated non-inferiority to Truvada in the DISCOVER trial, which means both drugs are equally efficacious 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.