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Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
Policy Number: PH-1129
CLINICAL RATIONALE The Affordable Care Act (ACA) requires a member-friendly mechanism for waiving the cost share for an alternative recommended product deemed medically necessary by the provider when a health care provider considers the $0 covered product is inappropriate for an individual. Prime Therapeutics offers a standard coverage exception/cost share waiver policy that is applied across all ACA categories.
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.html
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/aca_implementation_faqs26.pdf
Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Criteria
OBJECTIVE The intent of the ACA Prevention Copay Waiver Criteria is to help ensure the copay waiver, when applicable based on the member’s benefit, is applied to the appropriate population as described by the United States Preventative Services Task Force (USPSTF).
CRITERIA FOR APPROVAL The requested HIV infection pre-exposure prophylaxis (PrEP) agent will be approved when ALL of the following are met:
AND
AND
AND
OR
OR
OR
AND
AND
Length of Approval: 12 months
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment. ALBP_PS_ACA_Prevention_Copay_Waiver_HIV_PrEP_ProgSum_01-01-2024 |