As of July 1, 2017, United Healthcare (UHC) will require all its members using pre-exposure prophylaxis (PrEP) for HIV prevention to obtain prior authorization for Truvada (tenofovir/FTC) every three months for as long as they are on PrEP. UHC also will also require members to have their Truvada delivered by mail from its specialty pharmacy. These changes will make it more complicated and confusing to obtain the effective HIV prevention medication.
According to UHC, Truvada -- currently the sole U.S. Food and Drug Administration (FDA)-approved PrEP medication -- has become one of the top-ten most expensive drugs in their formulary. Increased cost is the main driver of this prior authorization implementation.
The National Coalition for LGBT Health believes that trying to control costs by limiting access to Truvada for PrEP is shortsighted. Currently, about 80,000 people in the United States are on Truvada for PrEP, and the Centers for Disease Control and Prevention (CDC) estimates that about 1.2 million people are good candidates for it. PrEP is almost 100% effective as HIV prevention, and it is intended to be taken during periods of high risk for HIV exposure. It is more efficient for overall health spending to pay for limited use of PrEP for prevention than for lifetime use of antiretroviral medications for treatment.
To obtain prior authorization, UHC members will have to go to their providers and have them fill out and send a form to the specialty pharmacy. The form includes four basic requirements: 1) a negative HIV test in the past two weeks, 2) a determination of "high-risk" status, 3) counseling on safe sex practices and 4) a lack of symptoms of acute HIV infection (fever, rash, sore throat, mouth ulcers, etc.). UHC requires the same process every three months. This checklist is in addition to the FDA-required HIV and sexually transmitted infection testing every three months and periodic kidney labs.
Prior Authorization and More Paperwork = More Barriers
The Coalition is deeply concerned about the changes to UHC's prescribing requirements. Requiring more paperwork and a specialty pharmacy adds barriers to accessing preventative care. The prior authorization requirement is transparently an attempt to increase the paperwork burden on prescribing providers to deter people from using PrEP.
The Coalition has interviewed PrEP users who are UHC customers. They are worried that there will be a delay in obtaining their medications. Switching to a new pharmacy and coordinating with their doctor's offices to obtain prior authorization takes time. The unending three-month cycle of prior authorization paperwork requires constant attention and a steady stream of phone calls and reminders to their providers.
These additional steps will make it much more difficult for people to consistently take Truvada. We need to be making it easier to get access to PrEP, not harder. Advocates have been conducting impactful and destigmatizing awareness campaigns to increase the use of PrEP -- and the campaigns are working. For example, HIV transmission rates in London fell precipitously last year, in large part due to a grassroots effort to increase PrEP use.
As part of its overall efforts to address the situation, the Coalition has prepared tips for PrEP access under the new UHC requirements. If you have questions, concerns or want to share your situation, leave a post or private message on our Facebook page or call 202-643-2107.
Benjamin Brooks is the manager of the National Coalition for LGBT Health in Washington, D.C. He guides the Coalition's education and advocacy efforts to increase health equity for LGBT communities.