(Reuters Health) – Widespread use of HIV preexposure prophylaxis (PrEP) in the U.S. may be curtailed by escalating out-of-pocket costs as well as total costs, which include the portion covered by government and private insurers, a new study suggests.
From 2014 to 2018, the number of annual prescriptions for PrEP climbed from 73,739 to 1,000,684. Over that period, average total payment for a 30-day supply of tenofovir disoproxil fumarate with emtricitabine (TDF-FTC) rose from $1,350 to $1,638, a 5% compound annual growth rate. The average out-of-pocket payment for TDF-FTC climbed from $54 to $94, a 14.9% compound annual growth rate, researchers report in Annals of Internal Medicine.
“The increasing cost of PrEP medication is paid by patients and insurers, and these increasing costs may present challenges for both,” study coauthor Dr. Nathan Furukawa, of the Division of HIV/AIDS Prevention at the U.S. Centers for Disease Control and Prevention in Atlanta, told Reuters Health.
In 2018, third-party payers covered 94.3% of total costs, or $1,544. Even though patients’ out-of-pocket costs amounted to 5.7%, or $94, over the course of a year this could total more than $1,000 and put the cost out of reach for some patients, the study team notes in their report.
“In response to these costs, insurers may deny coverage or implement prior authorization requirements,” Dr. Furukawa said by email. “This may reduce the ability of patients to initiate and persist on PrEP over time.”
Low-income patients covered by Medicaid had much lower out-of-pocket costs, at $3 for a 30-day supply, than patients on Medicare, who had average out-of-pocket costs of $80, and people with private health insurance, whose average out-of-pocket costs reached $107.
In 2018, mean out-of-pocket payments were lower for women ($72 for 30 tablets) than for men ($95 for 30 tablets), and they were also lower for teens ($37 for 30 tablets) than for older adults on Medicare ($117 for 30 tablets).
Mean out-of-pocket costs for 30 tablets also varied by region, from $79 in the West to $121 in the Midwest.
Overall, total PrEP medication payments roughly doubled each year from $114 million in 2014 to $2.08 billion in 2018, using multiply imputed payment data.
The analysis included prescription records from the IQVIA Longitudinal Prescriptions database, which includes records for 90% of prescriptions filled at retail pharmacies. One limitation of the study is that this database doesn’t include prescriptions from closed health systems like the Veterans Health Administration or Kaiser Permanente, leading to an underestimation of total medication payments, the authors note.
The researchers also lacked data on HIV risk factors or transgender identity, and had limited records on race/ethnicity, making it impossible to determine costs based on these variables.
Even so, the results highlight potential financial barriers to care, said Dr. Kevin Ard, director of the Sexual Health Clinic at Massachusetts General Hospital in Boston and co-author of an editorial accompanying the study.
Cost may directly stop some patients from starting or staying on PrEP because they can’t afford it, Dr. Ard said by email. And rising costs may also impact utilization indirectly due to challenges navigating health insurance, Dr. Ard added.
“Because most patients cannot afford the medication without some form of assistance – whether that be prescription drug coverage or a drug assistance program – assessing benefits and navigating assistance is part and parcel of starting PrEP,” Dr. Ard said. “This increases the hassle factor and may be another barrier for both patients and clinicians.”
SOURCE: https://bit.ly/2Fjlqq4 and https://bit.ly/3m51b0v Annals of Internal Medicine, online September 8, 2020.