HIV Care Value Program: Prevention and Predictability

Our new industry-first HIV Care ValueSM program, part of the SafeGuardRx® platform, will drive value and improve cost predictability for employers, health plans, and people at risk for HIV.

As champions for better, we have a bold goal of moving toward a future with zero new HIV diagnoses.

Such a bold goal requires a bold approach. To bring simplicity, affordability, and predictability to HIV prevention, we’re introducing the HIV Care ValueSM program - the industry’s first value-based program to help prevent the transmission of HIV through increased education and appropriate use of pre-exposure prophylaxis (PrEP) treatments. 

PrEParing for ACA Changes

In accordance with updates to the Affordable Care Act that take effect in July 2020, most employers and health plans will be responsible for providing coverage of PrEP with no cost-sharing for all people in their plans who are at risk for HIV exposure. These changes are based on recommendations from the U.S. Preventive Services Task Force in 2019 that found use of PrEP can substantially reduce the risk of HIV infection in persons at high risk.

Even with a zero-dollar copay, significant barriers to effective access remain, including proper use of PrEP therapy and physician awareness of updated rules and guidelines. High adherence to PrEP medication is especially critical to preventing HIV transmission, but is affected by stigma, low-risk perception, side effects, inaccurate information, and the logistics of daily life.

The ACA requirement is a big step toward removing the cost barrier for people who can benefit from PrEP with a goal of helping to end a global health epidemic; however, we need to address more than just the patient out-of-pocket costs. Express Scripts can uniquely ensure employers and health plans will be part of achieving the goal of significantly reducing HIV transmission.

Making Medicine Work Harder

The HIV Care Value program, part of the company’s industry-leading SafeGuardRx platform, includes three core elements to help employers and health plans address key barriers to access and effectiveness:

  1. Cost Predictability: To help employers and health plans continue to provide affordable, predictable health care coverage, Express Scripts will guarantee a maximum rate of growth of a plan’s spend on applicable HIV PrEP products, and will reimburse plans the amount that exceeds that trend guarantee dollar for dollar. This approach will help ease the strain plans will experience covering 100% of the cost for PrEP, and help prevent plans from having to shift costs to people in other ways.
  2. Patient Support:Patients on PrEP therapy will have access to specially trained clinicians through Express Scripts’ Therapeutic Resource Center® who will help patients overcome the many unique obstacles to optimal medication adherence with PrEP.
  3. Increased Awareness: Express Scripts will engage with providers to offer additional resources to help them educate their patients on HIV prevention. These efforts will help connect more at-risk people with PrEP therapy and other preventative measures while increasing awareness about the importance of medication adherence.

Open access is important to overcoming barriers to PrEP adherence. As such, members of plans enrolled in the HIV Care Value program can fill prescriptions for PrEP medications at any pharmacy within the plan’s network.

By taking a single pill once a day, people with an elevated risk can prevent contracting HIV. Yet, with a list price of $24,000 a year, PrEP has been out of reach for many of the people who need it most. With our new program, we will help employers and health plans ensure that every eligible person has the resources and support needed to use PrEP effectively and prevent HIV transmission.

Today, thanks to these lifesaving medications, people with HIV can live healthy lives, and we are now on a path to eliminating new infections. It will take every part of our health care system to see this through. We’re committed to doing our part.

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