Committee weighs no-cost PrEP/PEP coverage, 340B protections; decision held for more information

Legislative counsel told the Health & Welfare Committee on April 23 that draft amendments would require health insurance plans to cover HIV prevention drugs — including PrEP and PEP in oral and long-acting injectable forms approved by the FDA — with no deductible, coinsurance, copayment, prior authorization or step therapy.

Counsel said the package also adds a provision to protect 340B-covered entities: it would bar a prescription drug manufacturer or its agent from requiring a 340B covered entity or contract pharmacy to submit claims, utilization, purchase or encounter data as a condition of acquiring or receiving a 340B drug.

Medicaid representation, identified in the transcript as Alex McCracken, said Medicaid currently covers PrEP and some forms of PEP and that members who want access can obtain these medications. McCracken cautioned the committee that removing Medicaid’s ability to manage the class of drugs could reduce supplemental rebate revenue and “have a negative impact on our supplemental rebates or ability to capitalize on supplemental rebates,” and could increase program costs.

Courtney Harness of Blue Cross Blue Shield of Vermont said her carrier provides robust coverage but objected to the amendment’s no-cost-sharing provision and loss of certain management tools. "This language in this amendment would cost us between a $100,000 ... $200,000," Harness said, identifying the fiscal impact on her organization.

Stakeholders including an aid-service representative and committee staff said they had been exchanging language and were close to agreement on many points but still needed more time to reconcile Medicaid and insurer concerns. The committee agreed to hold the item open until Tuesday morning and asked staff to provide any outstanding information by 2:00 p.m. Monday to allow drafting of a revised amendment.

Next steps: the committee left the matter open for further drafting and requested that the Department of Financial Regulation be invited back to address whether any state defrayal of costs would be required under the proposal.