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PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans

PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans Benjamin Ryan © BSIP Image: Truvada. (BSIP / Universal Images Group via Getty) In a move that is expected to prove transformative to the national HIV-prevention effort, the federal government has announced that almost all health insurers must cover the HIV prevention pill, known as PrEP, or pre-exposure prophylaxis, with no cost sharing including for the drug itself and, crucially, for clinic visits and lab tests. This means the entire experience of maintaining a prescription to Truvada or Descovy, the two approved forms of PrEP, should now be totally free for almost all insured individuals. A prescribing physician, however, must persuade an insurer that Descovy in particular is medically necessary for any specific patient to qualify for zero cost sharing for that drug’s use as HIV prevention. 

Providers, payers see direct contracting s capitation as an important move to value-based care

Photo: Cecilie Arcurs/Getty Images Over the past several years, the big trend in healthcare has been to inch away from fee-for-servicereimbursement and toward value-based care, in which a provider s reimbursement is tied more to clinical quality than to volume. The industry, policymakers and the federal government have attempted this shift through a number of legal and regulatory means, and one policy that has proven popular in this regard, among both providers and payers, is direct contracting. In basic terms, direct contracting is a population-based model that allows for the use of capitation. This is what sets it apart: Aside from Next Gen and Pioneer, virtually all of the other compensation-based models from the Centers for Medicare and Medicaid Services are billed as fee-for-service, with a reconciliation 18 months later.

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