HIV Medications like PrEP and PEP are 99% effective. Here’s what you need to know about HIV and your health insurance, along with the associated medical care, such as doctor visits and lab tests.

The 1980s were a pivotal time. A decade defined by big hair, extreme fashion, rising global tensions, and some of the best pop culture to date. It was also the beginning of MTV, Madonna, Chicken McNuggets, Nintendo, and the AIDS epidemic.

Since 1981, more than 700,000 Americans have died from HIV-related complications. Today, HIV or AIDS is no longer the death sentence it used to be. However, the U.S. still sees 35,000 new infections every year with an estimated 1.2 million Americans at risk of infection. 

There are many options when it comes to HIV prevention and treatment, including life-saving medications. These drugs are not only highly effective, but when used for HIV prevention are fully covered by most insurance plans. And some are even available without a prescription.

Read on to learn more about these medications and what is covered by your health insurance.

HIV Medications & Treatments

Not only are there medications for staying HIV negative, but if you do test positive, there are even medications for suppressing the virus and averting further transmission.

For those at risk of HIV exposure, pre-exposure prophylaxis (PrEP) may be a good option. PrEP is taken regularly, and if taken as prescribed, largely reduces the chances of infection. Studies have shown it to be 99% effective. Being HIV negative and participating in routine check ups are required to get and maintain a prescription for PrEP. Options for mail-in HIV tests and telehealth visits are also available.

For those exposed to HIV, post-exposure prophylaxis (PEP) is highly effective in stopping infection, but available for emergency situations only. HIV can infect a person as quickly as 24 hours after contact. So every hour counts and the sooner treatment is started, the better! PEP must be taken within 72 hours of exposure and for 28 consecutive days to be effective. PEP is not suitable for regular use.

For people who are HIV positive, there are medicines available to help keep them healthy and prevent transmission to others. Antiretroviral therapy (ART) drugs reduce the amount of HIV in the blood, making the virus undetectable and, as a result, no longer transmittable.

HIV & What Your Plan Covers

Whether HIV-related medications are fully covered by your health plan at no cost to you depends on the diagnosis. When the drug is used for treatment, you will likely have to pay some of the costs (e.g., copay and deductible). If the drug is used as a preventive, there is no cost to patients for the medication or the required appointments and lab tests. Keep in mind, grandfathered health plans are exempt from the rules requiring these life-saving medications be free. That’s why it’s important to fully understand what your plan offers.

Each health insurance policy has an Evidence of Coverage, which is your guide to what is and isn’t covered by your insurer. This includes important cost-sharing information, such as what you pay and what your insurance pays, and all other coverage-related information. You can also find a list of the medications covered by your health insurance on your plan’s website. This is called a formulary.

If you have a plan through Covered California, and were charged for preventive care that should be free, you can find help here. Californians who have an HMO can call the Department of Managed Health Care at 888-466-2219. For all other health insurance plans (PPOs, EPOs, etc.), you can get assistance from the Department of Insurance at 800-927-4357.

No Prescription Required for PrEP & PEP

Since 2020, pharmacists have been authorized to furnish the life-saving HIV prevention drugs PrEP and PEP without a prescription. But they were authorized to only furnish a 30-day supply of PrEP, and up to a 60-day supply if certain conditions are met. A new law starting in 2024 allows pharmacists to now furnish a longer course of PrEP, up to a 90-day supply, still without a prescription. A longer course than a 90-day supply can also be provided if certain conditions are met. And, regardless if these medications are prescribed by a doctor, or provided directly by a pharmacist, the law requires that the costs be fully covered by health insurance, along with any related services and testing. As noted above, grandfathered health plans are exempt from covering these costs.

What If I am Uninsured?

If you’re without insurance, there are programs that can help with access to these life-saving medications. Ready, Set, PrEP makes PrEP available at no cost to those that qualify, for example. There are also assistance programs and state-level help for the associated lab tests and doctor visits. You can find similar options for PEP here. There are even more resources at the CDC’s website.

But getting quality health insurance is the best way to ensure you always have the care you need. All plans through Covered California include access not only to PrEP, but other preventive care, such as annual physicals and vaccinations, and for free. And, all of our plans include essential health benefits like emergency services, mental health treatment, and more.

If you’re at risk of exposure to HIV, have been exposed, or have HIV/AIDS, you cannot be denied coverage or charged more due to any pre-existing health conditions.

But more importantly, Covered California can help pay for health insurance. With financial help to lower the cost of coverage, many can get a quality health plan for less than $10 per month. And, there’s even more help available to reduce the cost of health care, like lowering copays and eliminating deductibles. Use our quick calculator tool to see just how affordable your health insurance can be.

What If I Have HIV or AIDS?

The AIDS Drug Assistance Program (ADAP) is for people diagnosed with HIV or AIDS. Established in 1987, the program helps ensure that HIV-positive, uninsured, and under-insured individuals have access to life-saving HIV-related medications. Individuals are eligible for ADAP if they are: a California resident, HIV infected, 18 years of age or older, and have an annual household income of not more than 500% of Federal Poverty Level (FPL). You can check your income level here.

Even if you have private health insurance through Covered California or elsewhere, ADAP may cover your prescription deductibles and copays for medications on their formulary. For more information or questions about ADAP’s medication program, call (888) 311-7632. Qualified individuals enrolled in ADAP can also receive financial help with their monthly premiums.

Getting Covered

There is a lot to consider when shopping for health insurance. Explore your options now and get the coverage you need through Covered California—or contact us at any time.

Covered California’s open enrollment period happens between November 1st and January 31st. If you don’t sign up during open enrollment, you may still be able to apply for health insurance and financial help to pay for it through Covered California under special enrollment.