HIV Prevention and Treatment Prescription Drug Coverage Guide

This is a summary of HIV prevention and treatment medications approved by the Food and Drug Administration (FDA) published in the US Department of Health and Human Services (HHS) and HIV.gov Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. It lists medications individually by treatment category, as well as by the most commonly prescribed medications by providers for consumers, as specified by the FDA. This resource does not offer clinical advice on medication regimens, rather lists coverage information in this manner for ease of consumer use.

Each insurance company has a list of prescriptions they cover, called a formulary or drug list, on their website. These lists often split drugs into ‘tiers’ or categories, which determine your share of the costs. Not all health plans cover all drugs or put them on the same tiers. Lower tiers generally mean generic and lower-cost drugs. Middle tiers often include brand name drugs. Higher tiers generally include specialty drugs or drugs administered in a medical facility. Each company tiers drugs differently, so it is important that you look at each plan specifically to see what medications may cost you. While some plans have a copay for prescriptions—a fixed amount that starts right away—other plans require you to pay the full cost until you hit a prescription deductible (if there is one) or your overall plan deductible, which is more common.  

The following tables summarize medication coverage for each insurance company offering individual (not through an employer) and small group plans (small employers with less than 100 employees) for 2024. They can be used to review the coverage and drug lists of HIV prevention and treatment medications by each insurance company. These tables do not review each plan or all formularies offered by each insurance company, and it is important for consumers to review each plan to confirm coverage as well as understand any prior authorization or medical management requirements.

Want to know if your prescription medication is covered? You can use the Quick Cost and Plan Finder tool offered by Connect for Health Colorado.

If you have any questions or concerns about your health insurance, please contact the Consumer Services Team for assistance: 303-894-7490 / DORA_Insurance@state.co.us / File a Complaint.

Key
(B) = Brand Medication
(g) = Generic Medication
NF = Non-formulary, exception required
P = Prevention $0 cost

This table of HHS Recommended HIV Treatment Medications is sorted by Drug Class. The formularies reviewed are hyperlinked to each company's title in the summary chart, and the FDA medication guideline document is hyperlinked in the title "Source: Source: U.S. Department of Health and Human Services (HHS) Recommended HIV Treatment Medications."

This table of HHS Recommended HIV Medications is sorted by Regimens / Combinations. The formularies reviewed are hyperlinked to each company's title in the summary chart, and the FDA medication guideline document is hyperlinked in the title "Source: Department of Health and Human Services Federally Approved Treatment & Prevention Guidelines for HIV/AIDS Adults and Adolescents."

HIV Prevention and Treatment Coverage Protections

Colorado insurance requirements specify certain protections for consumers who are at risk of or have HIV to ensure access to medically-necessary medications and other care.

• Coloradans may be prescribed Pre-Exposure Prophylaxis (PrEP) by a medical provider or pharmacist (§ 12-280-125.7, C.R.S.), and insurance companies must cover PrEP approved by the Food and Drug Administration (FDA), which may include Truvada (or its generic), Descovy, or Apretude, without copayment or other cost-share for adolescents and adults with an increased risk of HIV (See Colorado Insurance Regulation 4-2-73 for more information). 
• Insurance companies must also cover the required PrEP baseline and monitoring services without copayment or other cost-share. These services may include:  
  • Baseline and monitoring services include: HIV testing, Hepatitis B and C testing,
    creatinine testing and calculated estimated creatinine clearance (eCrCl) or glomerular
    filtration rate (eGFR), pregnancy testing, sexually transmitted infection screening and
    counseling, and adherence counseling.
• Office visits associated with baseline and monitoring services must also be covered without cost sharing, when the service is not billed separately from an office visit, and the primary purpose of the office visit is the delivery of the recommended preventive service.
• Insurance companies cannot limit or restrict the number of times that someone may start PrEP if the person meets the criteria specified in the USPSTF recommendation and PrEP is deemed to be medically appropriate by the individual’s health care provider.
• Insurance companies may not limit or restrict access to PrEP by restricting the number of times someone may start PrEP or impose additional utilization management procedures.
  • When PrEP is prescribed by a pharmacist, insurance companies may not require step therapy or prior authorization.
  • When PrEP is prescribed by a provider, insurance companies must process the request as an urgent prior authorization (see Colorado Insurance Regulation 4-2-49 for more information on urgent prior authorizations).
  • No more than 50% of drugs on a company’s prescription drug formulary used for the prevention or treatment of HIV may be placed on the plan’s highest cost formulary tier.

Appeals if Your Request is Denied

If you do receive a prior authorization denial or a post-service from your insurance company for your care you do have appeal rights. Individual plans, such as those you purchase yourself and that you don’t get through your employer, have a first level appeal process where they will re-review their denial if you or your care team file an appeal request within 180 days of the denial. Even if the denial is upheld after appeal, if it was denied as not being medically necessary, you may be able to request an independent external review by an independent third-party assigned by the Division. The results of an independent external review are binding on both the insurance company and the individual.

If you have any questions about prior authorization requests, appeals, denials, or a request for external review, please contact the Division of Insurance Consumer Services Team at 303-894-7490 / DORA_Insurance@state.co.us. You can also file a complaint online on the "File a Complaint" page of our website.