NASTAD PrEP Coverage Brief: PrEP Services Covered with No Cost-Sharing

This fact sheet walks through the coverage and cost-sharing requirements for public and private payers that come with this USPSTF Grade A recommendation. It summarizes federal guidance on implementing Preventive Services provisions of the Affordable Care Act (ACA), including new federal sub-regulatory guidance addressing PrEP services released on July 19, 2021.

Questions addressed include:

• What plans must cover PrEP without cost sharing?
• When do these new coverage and cost-sharing requirements for PrEP go into effect?
• What PrEP services have to be covered without cost sharing?
• Do individuals have to go to a particular provider to ensure there is no cost sharing?
• Can plans limit which patients are eligible for PrEP?
• Are there any billing considerations to ensure a service is categorized as an ACA Preventive Service that has to be covered without cost sharing?
• What should consumers do if a health plan is not providing PrEP without cost sharing?

Please contact NASTAD’s PrEP team at PrEP@NASTAD.org with questions or request TA on PrEP financing and coverage.