Minnetonka, Minnesota-based UnitedHealthCare ( UHC ) has implemented new requirements that many advocates and healthcare providers are describing as too onerous for individuals wishing to access PrEP, or pre-exposure prophylaxis.
Among the new rules, effective in July, are a requirement that customers acquire their medication through UHC's in-house mail-order pharmacy—a rule that customers have had inconsistent results in opting out of—and that physicians submit an intricate report on the patient four times a year, a task the insurer had previously only required annually.
AIDS Foundation of Chicago President/CEO John Peller said customer privacy should be a larger consideraton for UHC before it lays down rules such as the mail-order requirement.
"Forcing people to use mail-order is problematic for a number of reasons, one of which is individual privacy," he noted. "All of a sudden, you get prescriptions showing up on your doorstep. If you have family-members or roommates, or maybe even a partner, and you don't want them to know that you're on PrEP, or taking any medication that could get them to start to ask questions, it could be a problem."
Benjamin Brooks, manager of the Washington, D.C- based National Coalition for LGBT Health, said that the mail-order system is also problematic in that unstably-housed individuals using PrEP may not have a regular mailing-address, and that medications can be damaged by extreme temperatures.
"These are complicated medications, and there are reasons that there are temperature-safety protocols for them," added Brooks.
He noted that UHC customers using PrEP have reported a difficult time exercising an option to opt out of mail-delivery.
"I have communications from [UHC] members where they've been able to get an opt-out for a day, others who could get it from their pharmacy for a month, and others who could get it for a year, but the vast majority of people are telling me that they are unable to opt out at all," Brooks said.
Both he and Peller also suggested that the new physicians' requirements serve only to add a new layer of bureaucracy for UHC customers. Doctors must confirm that the patient is at risk for HIV infection; has received counseling on safe-sex practices and HIV risk reduction; has no symptoms consistent with HIV infection; and has an HIV-negative diagnosis from the previous two weeks.
Physicians responsibly prescribing the PrEP intervention do fulfill those requirements already, but UHC's rules slow that process with the quarterly paperwork requirement.
"What we want to see is a vast expansion of PrEP services, and instead we're seeing that doctors are having more resources devoted to paperwork, taking them away from providing needing resources to their patients," Brooks said.
The PrEP intervention, usually available in the form of the oral medication Truvada, is being used by between 80,000-100,000 people in the United States, according to estimates, and can reduce the risk of an HIV infection by more than 90 percent. But widespread implementation of PrEP has been stymied by a number of factors, among them the difficulties of mounting education and information campaigns for diverse audiences, lingering stigma against persons with HIV/AIDS and the high price of the medication.
Indeed, the cost of Truvada, manufactured by Foster City, California-based Gilead Sciences, Inc., can be as much as $1,800 for a month's supply. That is UHC's motivation for the new requirements; the insurer has said that Truvada is one of the most expensive medications in its formulary.
"In a case like this, where we're talking about an insurance company and drug-pricing, it takes two to tango," Peller said. "We are also calling on Gilead to look at their pricing on Truvada. If they were making concessions on price that were commensurate with the increased volume that United is seeing, United would not be placing limitations of this degree on Truvada."
UHC and its sister company, Optum, insure about 115 million people in this country. Windy City Times asked UHC and Gilead to comment on the change in regulations and the cost of the Truvada medication; however, neither company had responded by the press deadline.
