ASSOCIATION OF PLAN CHARACTERISTICS AND HIV OUTCOMESWITHPREPTHERAPY ACCESS ON COMMERCIAL FORMULARIES
Author(s)
Yevgeniy Feyman1, Hanke Zheng, MS, PhD2, Jon Campbell, PhD2;
1Washington, DC, USA, 2National Pharmaceutical Council, Washington, DC, USA
1Washington, DC, USA, 2National Pharmaceutical Council, Washington, DC, USA
Presentation Documents
OBJECTIVES: Preexposure prophylaxis (PrEP) for preventing HIV transmission received an “A” rating from the United States Preventive Services Task Force, indicating substantial net benefit from the treatment. We explored formulary restrictiveness of PrEP among commercial plans in the United States, and associations with state-level HIV outcomes.
METHODS: We used Clarivate’s Fingertip Formulary from December 2016 through 2025 and data from AIDSvu.org from 2016 to 2023. We used linear regressions with year, drug, plan type, PBM, state, and payer fixed effects to examine associations of formulary restrictiveness with plan characteristics. We used state-level Poisson regressions with state and year fixed effects to assess association between formulary restrictiveness with state-level number of new HIV diagnoses and PrEP-to-need-ratio (number of individuals taking PrEP to new HIV diagnoses).
RESULTS: In 2025, across all PrEP therapies, 29.6% of enrollees were in plans with non-zero copays while 27.4% were in plans with non-zero coinsurance; 53.6% of enrollees were in plans where all covered PrEP therapies faced no cost-sharing. Linear regression indicated that relative to standard commercial plans, PBM-insurer offered plans and Union plans had lower copays (-$18.21, SE:$4.78; -$18.98, SE:$7.72). When offering coinsurance, PBM-insurer plans had higher coinsurance ($8.61, SE:$2.07); marketplace plans had lower coinsurance (-$2.49, SE:$1.06). Poisson regressions indicated a one percentage point increase in average PrEP coinsurance was associated with a 0.5% (SE:0.2) increase in the number of new HIV diagnoses. Linear regressions suggested a 0.15 (SE:0.07) reduction in PrEP-to-need ratio for a one percentage point increase in coinsurance.
CONCLUSIONS: These findings suggest that comprehensive coverage of PrEP without cost sharing is lacking despite the USPSTF "A" rating and Affordable Care Act mandates. Among commercial plans, certain plan types had fewer financial barriers to accessing PrEP therapy. At the state-level, lower rates of coinsurance were associated with lower rates of HIV diagnoses and more utilization of PrEP.
METHODS: We used Clarivate’s Fingertip Formulary from December 2016 through 2025 and data from AIDSvu.org from 2016 to 2023. We used linear regressions with year, drug, plan type, PBM, state, and payer fixed effects to examine associations of formulary restrictiveness with plan characteristics. We used state-level Poisson regressions with state and year fixed effects to assess association between formulary restrictiveness with state-level number of new HIV diagnoses and PrEP-to-need-ratio (number of individuals taking PrEP to new HIV diagnoses).
RESULTS: In 2025, across all PrEP therapies, 29.6% of enrollees were in plans with non-zero copays while 27.4% were in plans with non-zero coinsurance; 53.6% of enrollees were in plans where all covered PrEP therapies faced no cost-sharing. Linear regression indicated that relative to standard commercial plans, PBM-insurer offered plans and Union plans had lower copays (-$18.21, SE:$4.78; -$18.98, SE:$7.72). When offering coinsurance, PBM-insurer plans had higher coinsurance ($8.61, SE:$2.07); marketplace plans had lower coinsurance (-$2.49, SE:$1.06). Poisson regressions indicated a one percentage point increase in average PrEP coinsurance was associated with a 0.5% (SE:0.2) increase in the number of new HIV diagnoses. Linear regressions suggested a 0.15 (SE:0.07) reduction in PrEP-to-need ratio for a one percentage point increase in coinsurance.
CONCLUSIONS: These findings suggest that comprehensive coverage of PrEP without cost sharing is lacking despite the USPSTF "A" rating and Affordable Care Act mandates. Among commercial plans, certain plan types had fewer financial barriers to accessing PrEP therapy. At the state-level, lower rates of coinsurance were associated with lower rates of HIV diagnoses and more utilization of PrEP.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
EPH57
Topic
Epidemiology & Public Health
Topic Subcategory
Public Health
Disease
SDC: Infectious Disease (non-vaccine)