Using PrEPcost.org

Using PrEPcost.org 

Download the 2020 Open Enrollment Manual here.

Copay Accumulator Policies

A co-pay accumulator policy is when an insurance plan or its pharmacy refuses to count a manufacturer co-pay card or similar programs towards that person’s deductible or plan annual out-of-pocket maximum.

NASTAD is monitoring co-pay accumulator policies. If you come across a health plan with this type of policy in place, please let us know at PrEP@NASTAD.org. Please include the zip code, the name of the health insurance carrier, and the health plan name or ID.

PrEPcost.org FAQs

Will PrEP be covered as a preventive service at no cost beginning in 2020?

PrEP will be covered at no cost to the patient as a preventive service starting in January 2021. New York State has issued guidance requesting that health plans sold in the state should cover the intervention as soon as possible and not wait until 2021. Background: The US Preventive Services Taskforce (USPSTF) issued a grade A recommendation for PrEP in May 2019. Under ACA, these preventive services must be covered by Medicaid expansion programs and Qualified Health Plans at no cost to the patient. NASTAD is engaging with federal and state regulators to encourage them to issue guidance to clarify that the recommended clinical visits and lab tests are an integral part of any PrEP program and should also be covered at no cost to the patient.

s PrEPcost.org useful for Certified Application Counselors (CACs)?

Yes, absolutely! Even CACs who are not working exclusively with PrEP patients can use PrEPcost.org to browse plan options in their area, verify plan information and costs, estimate eligibility for Marketplace financial assistance, access plan documents and formularies, and more. If a CAC is not available to you, feel free to reach out to HealthSherpa for assistance with plan assessment and enrollment.

What are the lab tests that are included in your assumptions?

Detailed information about the cost assumptions on PrEPcost.org can be found in the 2020 Open Enrollment User Manual.

Is the full list of CPT codes for PrEP appointments included in the user manual?

Yes. Detailed information about PrEP services included in the cost assumptions on PrEPcost.org can be found in the 2020 Open Enrollment User Manual.

Does NASTAD have a list of alternative financial support programs for PrEP?

Yes. A list of private and public financial support programs for PrEP can be found on our PrEPcost.org resources page.

Are plans required to provide information about whether and to what extent they will apply a copay accumulator policy?

There is no transparency requirement related to copay accumulator policies. Although we have generally found that it’s written somewhere, there is no uniformity and no guarantee that every plan will make this publicly known. A plan that does not mention copay accumulator policies in its written policies may still refuse to count manufacturer coupons towards the deductible and MOOP. Download NASTAD’s brief on copay accumulators for more information.

What options are available for patients using Medicare?

Good Days offers co-pay assistance for PrEP for individuals with Medicare or Military insurance coverage. Co-pay assistance from the PAN Foundation may also be available for PrEP patients with Medicare coverage, although this program is currently closed. 

Does PrEPcost.org include Medicare Part C and D plans?

No. PrEPcost.org only includes individual plans available through the Health Insurance Marketplace.

Does the "Annual PrEP Expenses" per plan include premiums?

The “Annual PrEP Expenses” figure displayed on the plan search results page reflects out-of-pocket costs for PrEP for the year—12 months worth of prescriptions, quarterly provider visits, and quarterly lab tests. This figure does not include premiums. However, when you sort plans by “Annual Cost,” the plan at the top of the page will have the lowest total annual cost—this includes Annual PrEP Expenses plus 12 months of premiums. For more information about how to use PrEPcost.org, refer to the 2020 Open Enrollment User Manual.

Determining Medicaid eligibility and eligibility for advance premium tax credits

 

Medicaid Eligibility Determination

PrEPcost.org does not provide a determination of eligibility for financial assistance. Although PrEPcost.org can estimate financial assistance accurately for most people seeking self-only coverage whose incomes are between 100% FPL (or 138% FPL in Medicaid expansion states) and 400% FPL, there are many factors that the site does not take into account.

For consumers whose incomes are very close to the Medicaid cutoff, it is recommended that they complete the Medicaid eligibility process.

Lawfully Present Non-citizens

Lawfully present non-citizens with incomes below 100% (in non-expansion states) or 138% FPL (in expansion states) may be eligible for 97% CSR silver plans. PrEPcost.org does not screen for lawfully present non-citizens who may be eligible for 97% CSR silver plans due to their immigration status. PrEPcost.org can still help compare plans based on PrEP out-of-pocket expenses, but the PrEP assister would need to enter an income that “unlocks” the 97% CSR silver plans. However, APTC amounts on PrEPcost.org would still be incorrect because the site cannot calculate APTC for individuals who are below the income cutoff for APTC eligibility in their state. The PrEP assister can work together with the consumer and the experts at HealthSherpa to help the consumer understand how much PrEP will cost under each plan.

Medicare Enrollees and Medicare-eligible Consumers

PrEPcost.org does not screen for Medicare eligibility. Consumers who are eligible for premium-free Medicare Part A are ineligible for Marketplace coverage, and those who pay a premium for Part A must drop that coverage before enrolling in a Marketplace plan. Consumers who may be eligible for Medicare should confirm their Medicare eligibility and enrollment status before purchasing Marketplace coverage.

Household Size  

PrEPcost.org estimates financial assistance for a one- or two-person household, but only displays plans that cover one person. Consumers with more complex households should submit a Marketplace application through HealthSherpa.

Family Plans

Individuals in a household with two or more people may be eligible for additional tax credits not included in the estimate, or for Medicaid or CHIP. Consumers who are looking to purchase family coverage should rely upon HealthSherpa for plan comparison and enrollment.

Special Medicaid Eligibility Categories

PrEPcost.org screens for Medicaid eligibility based only on income, and only for eligibility under the Medicaid expansion. The site will not screen consumers who are eligible for Medicaid under a traditional eligibility category, including pregnancy. PrEP assisters who are more knowledgeable about Medicaid eligibility may identify consumers who are potentially eligible for Medicaid and refer them to HealthSherpa.