Out-of-pocket costs for PrEP ancillary services among U.S. commercially insured persons, 2017-2022

We assessed annual out-of-pocket (OOP) costs for HIV preexposure prophylaxis (PrEP)-related services among commercially insured individuals in the U.S. before and after the Affordable Care Act (ACA) mandated no cost-sharing in 2021.

Using data from a large commercial database, we identified persons aged ≥18 years who were prescribed PrEP from 2017-2022. Medical claims for PrEP-related services submitted within one week before each PrEP prescription were extracted using CPT codes. For each service, we calculated the annual proportion of persons incurring OOP costs and associated annual amounts, adjusted to 2022 U.S. dollars. We assessed trends in the proportion of persons with OOP costs for each service from 2019-2022. We also examined the association between OOP cost occurrence and patient demographic characteristics.

Among 141,300 PrEP users, we observed decreasing trends in the proportion incurring OOP costs for PrEP ancillary services over the study period. In 2022, OOP costs were incurred by 65.6% for provider visits, 14.3% for HIV testing, and 32.5% for creatinine testing, with mean OOP costs of $54.18, $26.06, and $6.07, respectively. Rural users were more likely to incur costs than urban users.

Despite ACA mandates, many persons received cost-sharing bills for PrEP services. Standardized billing and coding, along with enhanced monitoring and enforcement, could help protect access to evidence-based preventive care.