Prior Authorizations Pose Barrier to Access for HIV Preexposure Prophylaxis


The study authors reported that plans in the South had the highest rates of exclusive PAs for either emtricitabine/tenofovir disoproxil fumarate or emtricitabine/tenofovir alafenamide even if the plan covered both, from 2018 to 2020.

High rates of prior authorizations (PAs) could prevent HIV preexposure prophylaxis (PrEP) access and uptake in areas that have high rates of the disease, according to results of a study published in JAMA Network Open. Investigators call for policies that address PrEP as a health equity crisis, including policies around regulatory actions and national programs.1

PrEP Pill | Image Credit: magann -

magann -

The study authors aimed to assess qualified health plan coverage, PA requirements, and the plan’s specialty drug tiering of emtricitabine/tenofovir disoproxil fumarate (Truvada; Gilead) as well as emtricitabine/tenofovir alafenamide (Descovy; Gilead) for PrEP treatment, determining the role these factors play in access. Investigators included qualified health plan in the United States from 2018 to 2020, which were categorized by region and Ending the HIV Epidemic Initiative (EHE) priority jurisdiction.1 The EHE is a program by the US Department of Health and Human Services aimed at reducing new HIV infections by 75% by 2025 and 90% by 2023, according to the CDC.2 The qualified health care plans were also compliant with the Patient Protection and Affordable Care Act, according to the study authors.1

Investigators analyzed the data from March 2022 to March 2023, including data on the annual variation of qualified health coverage plans and PA requirements for the drug regimens of interest. A key secondary outcome included if the PrEP formulas were placed on a specialty drug tier by the health plan, according to the study authors.1

There were 19,533 qualified health plans used from 2018, 17,007 from 2019, and 21,547 from 2020, totaling 58,087 plans. Approximately 98.1% covered emtricitabine/tenofovir disoproxil fumarate in 2018, 99.8% in 2019, and 94.8% in 2020 compared to emtricitabine/tenofovir alafenamide at 91.9%, 92.7%, and 87.4%, respectively.1

The study authors reported that plans in the South had the highest rates of exclusive PAs, a PA for 1 formulation even if the plan covered both, in all 3 years. The Northeastern region has similar rates of both formulations from 2018 to 2020. In the Western region, the coverage of both formulations was high from 2018 to 2020, and in the Midwestern region, the coverage of both was common in health plans.1

Furthermore, the rate of PAs for emtricitabine/tenofovir disoproxil fumarate increased from 10% in 2018 to 46.8% in 2020 in the South, according to the results. The investigators also reported that emtricitabine/tenofovir disoproxil fumarate had a higher rate of exclusive PA requirements in places with EHE jurisdiction compared to non-EHE jurisdiction, at a difference of 0.9 percentage points in 2018, 3.5 in 2019, and 29.1 in 2020.1

Further, emtricitabine/tenofovir disoproxil fumarate was more likely to be placed in a specialty tier compared with emtricitabine/tenofovir alafenamide, at a difference of 1.8 percentage points in 2018, 3.7% in 2019, and 4.1% in 2020, according to the results. The Midwest was also more likely to have emtricitabine/tenofovir disoproxil fumarate in a specialty tier when compared to other regions, the investigators reported.1

The study authors said that the limited access and cost barriers of PrEP indicate a need for a federal response to further develop care and treatment for those with HIV.1


  1. McManus KA, Fuller B, Killelea A, Strumpf A, Powers SD, Rogawski McQuade ET. Geographic Variation in Qualified Health Plan Coverage and Prior Authorization Requirements for HIV Preexposure Prophylaxis. JAMA Netw Open. 2023;6(11):e2342781. doi:10.1001/jamanetworkopen.2023.42781
  2. Centers for Disease Control and Prevention. Ending the HIV Epidemic in the US (EHE). June 9, 2023. Accessed November 20, 2023.
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