UnitedHealthcare refuses PrEP drug for ‘high risk homosexual behavior’

by Rob Howard
Associate Editor

Since 2012, Truvada has been the pre-exposure  prophylaxis (PrEP) drug of choice for people who are HIV- but at high risk for contracting HIV. Condemned by some as a drug to make high-risk behavior more safe, it is applauded by most in the LGBT+ community and the health care provider community as helping in the effort to stamp out the spread of HIV.

“Without insurance, PrEP costs about $1300 per month, plus the added expenses of office visits and lab work. But most insurance providers cover at least part of the drug’s cost, since it is generally cheaper to pay for prevention than to cover the costs of treating people infected with HIV,” said PBS.org in 2015.

Apparently, UnitedHealthcare, the nation’s largest insurer, didn’t get the news on that. According to multiple sources, they refused to approve coverage for Truvada to a New York gay man because, ““the information you sent in shows you are using this medicine for high risk homosexual behavior.”

“A letter from United HealthCare posted in a Facebook group for HIV awareness showed the insurer declined to pay for the man’s prescription for Truvada, which treats and reduces the risk of HIV infection and would cost up to $1,500 a month out of pocket,” reported RawStory.com.

“’This decision is based on health plan criteria for Truvada,’ the letter reads. ‘The information sent in shows you are using this medicine for engaging in High risk homosexual behavior,” reported RawStory.com.

According to UnitedHealthcare’s Prior Authorization/Notification document for Truvada, the drug can only be used for “HIV Infection, Post exposure prophylaxis (PEP to reduce the risk of HIV infection from either an occupational or non-occupational known or suspected possible exposure to the HIV virus, or for Pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 infection in adults at high risk.”

The criteria for PrEP are listed in the document.

“Truvada will be approved based on all of the following criteria:

(1) Patient has been determined to be at high risk for HIV-1 infection -AND- (2) Patient has received counseling on safe sex practices and HIV infection risk reduction. -AND- (3) Patient has no clinical symptoms consistent with acute viral infection -AND- (4) Patient has a confirmed negative HIV-1 status within the past 2 weeks.”

If those conditions are met, “authorization will be issued for 3 months.”

Reauthorization will be allowed based on the following criteria:

“(1) Patient has been determined to be at high risk for HIV-1 infection despite prior counseling on safe sex practices and HIV infection risk reduction -AND- (2) Patient continues to receive counseling on safe sex practices and HIV infection risk reduction -AND- (3) Patient has no clinical symptoms consistent with acute viral infection -AND- (4) Patient has a confirmed negative HIV-1 status within the past 2 weeks.”

Reauthorization will be issued for three months.

Apparently UnitedHealthcare doesn’t comprehend that there are several reasons for people to be at high risk for contracting HIV. Number one on the list would be in a situation where one partner in a couple is HIV+ and the other is HIV-.

United Healthcare changed its mind for the patient who was refused, and approved his use of Truvada, but it is not clear if every person applying to use the drug would have to jump through the same hoops to gain approval.

Copyright 2017 The Gayly – August 3, 2017 @ 4:25 p.m. CDT.