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.

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.