Alberta Health PrEP Coverage
Starting October 1, 2018, Alberta Health will provide full coverage for generic versions of PrEP for eligible Albertans. To access this coverage, individuals must:
1) Have Alberta Health Care (individuals may be required to produce their Alberta Personal Health Care Card to be eligible for coverage)
2) Meet the eligibility criteria as laid out in the provincial PrEP guidelines.
First Nations and Inuit individuals with Alberta Health Care may also access coverage through the provincial program. However, it should be noted that eligible First Nations and Inuit can continue to access full PrEP coverage through Non-Insured Health Benefits (NIHB), under the First Nations and Inuit Health Branch (FNIHB).
Who meets the eligibility criteria for publicly funded PrEP under the provincial PrEP guidelines?
[Note: This language is pulled directly from the provincial PrEP guidelines and may differ from the language some people use to describe their experiences]
1. MSM, Trans Women and Gender Diverse People
Condomless anal sex within the last 6 months and any of the following:
Infectious syphilis or bacterial STI (gonorrhea or chlamydia) in the past 12 months. This recommendation is expanded from the Canadian criterion specifying rectal bacterial STI given the limited uptake of extra-genital testing in Alberta).
nPEP (non-occupational HIV post-exposure prophylaxis) more than once
Ongoing sexual relationship with HIV-positive partner(s) with substantial risk of transmissible HIV (ie-viral load detectable; >40 copies/mL* or HIV status unknown but from a higher risk population- eg MSM, PWID)
HIRI-MSM risk score ≥ 11 (HIV Infection Risk Index for MSM; see Appendix A: HIRI-MSM risk assessment tool)
Not indicated for those in a monogamous relationship with a single partner with no or negligible risk of having transmissible HIV (e.g. HIV negative, HIV positive but virus suppressed with viral load ≤ 40 copies/mL, or HIV status unknown but risk profile similar to the general population (Tan et al 2017)).
Gender diverse people are included in the eligibility criteria as incorrect assumptions can be made about sexual practices of individuals.
2. Heterosexual People
Recommended for the HIV-negative partner in an ongoing relationship with an HIV-positive partner involving condomless vaginal or anal sex, where the HIV-positive partner has a substantial risk of having transmissible HIV (ie-detectable viral load*)
Consider PrEP in similar situations where the HIV-positive partner has a lower, but non- negligible risk of transmissible HIV:
viral load detectable (>40 copies/mL*) or
viral load usually undetectable* but concomitant STI present at time of exposure (recognizing that undetectable viral load gives a very low likelihood of transmission, but the presence of an STI may increase the presence of virus in ulcers (Boily MC et al 2009) or at mucosal surfaces), or
HIV status unknown, but from a high-prevalence population- MSM, PWID, countries with high HIV prevalence
3. PWID (People Who Inject Drugs)
PrEP may be considered when there is ongoing or anticipation of ongoing sharing of injection drug use paraphernalia (needles, syringes, spoons, foil, cotton filters etc.) with a person with a non-negligible risk of HIV infection:
Detectable viral load* or
HIV status unknown but from a high-prevalence population- MSM, PWID, countries with a high HIV prevalence.
*for the purposes of this document, an undetectable viral load is defined by 2 sequential measurements of HIV viral load <40 copies/mL on at least 2 occasions separated in time by 4-6 months.
For more information on whether PrEP is right for you or your patient visit our “Is PrEP right for you?” page (for community members or "Assessing for Eligibility" page (for patients). And if you have any other questions, please do not hesitate to contact us here.
Who is eligible to prescribe publicly funded PrEP?
In order for a patient to access PrEP coverage through Alberta Health, they must receive a prescription from a designated prescriber. Currently, only physicians and nurse practitioners are eligible to become designated PrEP prescribers as it relates to the province’s publicly funded PrEP program.
To become a designated prescriber, those eligible must complete a module (with online and in-person deliveries), after which they will be added to the designated prescriber list. For those with significant experience prescribing PrEP in the past, an exception to the module may be permitted.
For eligible prescribers interested in being added to the designated prescriber list, they should fill out the Designated Prescriber Application form found on the AHS PrEP page.
Any prescriptions provided by non-designated prescribers will not be eligible for coverage under the provincial PrEP program. If you are currently being prescribed PrEP and would like your prescriber to be contacted about these new requirements, please complete the following google form.
For a current list of designated prescribers, click here.
To visit the AHS PrEP webpage, click here.
Currently, this is not a requirement for individuals who are obtaining PrEP coverage through Non-Insured Health Benefits or for those who obtain private insurance coverage for PrEP or pay out-of-pocket.
Unfortunately, we recognize that not everyone who lives in Alberta will be eligible for publicly funded PrEP coverage. In this case, individuals will likely have to pay out-of-pocket or obtain coverage through a private insurer. To learn more about alternative coverage pathways, read on below.
PrEP Options (and Costs)
If you are unable to access public coverage for PrEP, you will likely have to consider paying out-of-pocket or attempting to obtain coverage through your private insurance plan. Fortunately, with generic versions of PrEP now available on the Canadian market, you have more (and cheaper) PrEP options than ever before. An overview of PrEP options and their related costs is as follows:
[Note: The following prices include maximum pharmacy markups and dispensing fees. The current pharmacy fee structure in Alberta allows for an initial 3% markup on medication, followed by a secondary markup of 7% [up to $100], and a dispensing fee of $12.30. Most pharmacies do not charge the maximum allowable [including all markup and dispensing fees], meaning that you might be able to find some of these medications for slightly cheaper depending on where you have your prescription filled. Finally, manufacturers can change prices with little or no notice. If you find you are able to access these medications from a pharmacy in Alberta for a different price than listed below, please let us know here.]
Gilead: The most commonly known option for PrEP is known by the brand name, Truvada. The cost of Truvada is approximately $1,010 for a one month/30 pill supply. Truvada has been approved by Health Canada for use as PrEP since February 2016.
Mylan: Mylan's version of TDF/FTC costs approximately $265 for a one month/30 pill supply. Mylan’s generic version of TDF/FTC was recently approved for use as PrEP in Canada.
Teva: Teva’s generic version of TDF/FTC costs approximately $520 for a one month/30 pill supply. Teva's version of TDF/FTC has already been approved for use as PrEP in Canada.
Apotex: Apotex's generic version of TDF/FTC costs approximately $520 for a one month/30 pill supply. Apotex has been approved for use as PrEP in Canada.
[Note: Another generic version of TDF/FTC, manufactured by Pharmascience, has also been approved by Health Canada, including for use as PrEP. To the best of our knowledge this drug is not currently available in Alberta]
How Much Will PrEP Cost You?
Historically people have experienced difficulty obtaining reimbursement for PrEP through their prescription drug insurance plan. However, as PrEP has become more mainstream and more TDF/FTC options have been approved for use as PrEP, more individuals are experiencing success in obtaining coverage for PrEP. This section will provide you with some practical information regarding how much you can expect to pay for PrEP as well as some practical steps you might need to take to successfully obtain coverage through your insurance provider.
How much PrEP will actually cost you depends on a few different things:
1) How much you pay for insurance and whether or not you’re obtaining insurance solely to cover your PrEP prescription. If you already have or would already be getting prescription drug coverage anyway, regardless of PrEP, then there’s no need to add your policy premium to your PrEP costs (unless you end up switching to a more expensive plan to obtain better PrEP coverage). However, if you purchase insurance solely for PrEP coverage, you might choose to factor this into your overall PrEP costs. From our research, most policies in Alberta will cost you between $50-$150 per month (this does not include government-sponsored plans or group plans obtained through an employer where the employer pays a portion of the premium). And although the PrEP coverage landscape continues to evolve, with insurance plans covering PrEP now which didn’t cover PrEP previously, historically PrEP is more likely to be covered by higher-tier (AKA more expensive) plans.
2) What portion of your PrEP prescription is covered by your insurance policy vs. how much you’re expected to pay out-of-pocket (this is considered your co-pay). Finding a plan that will cover PrEP at a reasonable premium is not the only thing you need to look out for. There’s also the issue of what percentage of your prescription costs are covered by your insurance company. For example, some plans might cover as little as 60% toward the cost of your prescription while others might cover 80 or 90%. Whatever percentage your insurer doesn’t cover is paid out-of-pocket by you. So, perhaps you pay a little less premium for the first option, which just covers 50-60%. However, thinking of Truvada, a difference of 20-30% in coverage could be equivalent to an extra $200-$300 you have to pay out of your own pocket.
3) Whether your insurance policy has an annual limit and whether your PrEP prescription (in combination with other prescriptions you are filling) surpasses that limit, meaning you would need to pay the remainder. Like above, insurance plans also have differences related to annual caps or limits. So, regardless of what percentage they pay toward your prescriptions, they will only reimburse you up to a certain limit for the entire year. Once you surpass this limit, the remainder of your medications will have to be paid 100% out-of-pocket by you. In that sense, depending on the overall annual cost of all of your prescriptions, a plan that covers 70% toward your prescriptions with an annual limit of $7000 could be more suitable for your needs than a plan that covers 80% of your prescription drug costs up to a limit of only $2000.
To better illustrate how these elements can affect how much you pay for PrEP, here are a couple of examples (prices based on max markup and dispensing fees):
Scenario No. 1: Insurance pays nothing and you pay 100% out of pocket.
Mylan: $265/month = $3,180/yr
Apotex & Teva: $520/month = $6,240/yr
Truvada: $1,010/month = $12,120/yr
Scenario No. 2: You purchase insurance solely for PrEP coverage. It costs you $100 per month. It covers 80% of your prescriptions up to an annual limit of $5,000.
Insurance pays 80%: $212/month = $2,544 (within annual limit)
Individual pays 20% co-pay: $53/month = $636
Premium: $100/month = $1,200
Total Annual PrEP Cost: $1,200 (Premium) + $636 (Co-Pay) = $1,836
Apotex & Teva
Insurance pays 80%: $416/month = $4,992 (within annual limit)
Individual pays 20% co-pay: $104/month = $1,248
Premium = $100/month = $1,200
Total Annual PrEP Cost: $1,200 (Premium) + $1,248 (Co-Pay) = $2,448
Insurance pays 80%: $808/month = $9,696 (over annual limit by $4,696)
Individual pays 20% co-pay: $202/month = $2,424
Premium: $100/month = $1,200
Total Annual PrEP Cost: $1,200 (Prem) + $2,424 (Co-Pay) + $4,696 (above limit) = $8,320
(If you already have prescription drug coverage or would be obtaining it regardless of accessing PrEP, you can subtract $1,200 per year of premium off the total annual PrEP cost)
Scenario No. 3: You already have and would maintain prescription drug coverage regardless of accessing PrEP and therefore don’t factor your insurance premium into your overall PrEP costs. Your plan covers 80% up to a total of $10,000. Your insurance plan will only reimburse for Truvada and will not provide reimbursement for any of the generic equivalents.
Insurance pays 0%: $0
Individual pays 100%: $265/month = $3,180
Total Annual PrEP Cost: $3,180
Apotex & Teva
Insurance pays 0%: $0
Individual pays 100% co-pay: $520/month = $6,240
Total Annual PrEP Cost: $6,240
Insurance pays 80%: $808/month = $9,696 (within annual limit)
Individual pays 20% co-pay: $202/month = $2,424
Total Annual PrEP Cost: $2,424
These examples, while not exhaustive, illustrate a few key things:
1) Although challenging at times, finding an insurance plan which provides adequate coverage for PrEP can help mitigate the high costs of PrEP (even generics) and is almost always a cheaper option than paying 100% out-of-pocket.
2) The various elements of your prescription drug plan can have a significant impact on the amount of money you pay for PrEP. When sizing up your policy, you should consider what your monthly premium is (particularly if you’re purchasing your policy primarily for PrEP coverage), the percentage your policy pays towards prescriptions, what your policy’s annual limit or cap is and whether or not PrEP, combined with your other prescriptions would surpass it.
3) You will want to determine which PrEP options your insurance policy does and does not cover. For example, there could be circumstances wherein Truvada, when covered at 80% and within your policy's annual limit, is cheaper than paying for Mylan out-of-pocket.
[Note: Some of this information is expected to change given Alberta Health's recent decision to fund PrEP for eligible Albertans. We will be updating this section in the coming weeks to reflect such changes. If you have any questions or concerns, please do not hesitate to contact us here].
Non-Insured Health Benefits (NIHB), within Health Canada’s First Nations and Inuit Health Branch (FNIHB), provides coverage for registered First Nations and recognized Inuit. Last updated on June 29, 2017, Truvada is listed as an open benefit under the NIHB program. Prospective PrEP users may receive 100% coverage for brand product (NOT generic options).
Third-Party (Private) Insurance Plans
There are a number of private insurance providers (i.e. Sun Life, Manulife, Great West Life, Desjardins, etc.). If an individual is a part of a group plan administered through any of these private insurers, the insured member must consult their policy provider to find out details of their coverage (your human resources department can help you locate the number). Most insurance providers offer an online service where the insured member is able to search for coverage status and eligibility criteria by entering the Drug Identification Number (DIN) of the desired drug product. The DIN numbers for currently marketed TDF/FTC options are:
Truvada – 02274906
Mylan – 02443902
Teva – 02399059
Apotex – 02452006
Although this online lookup may indicate coverage through the policy it does not mean the claim will be automatically accepted by the insurer. You should follow-up with the insurer directly to find out if there are any further stipulations to coverage related to the TDF/FTC.
Documents you might need
Drug Special Authorization or Exception Form
If your policy does not generally cover TDF/FTC or does not commonly cover it for use as PrEP, your insurance company might require a form to be filled out by your physician explaining why you are being prescribed the drug and why it should be covered under your insurance policy. Check with your insurance provider to see if they have a standard form.
Ask for Help
We hope that the information above provides some practical guidance on how to obtain PrEP coverage. However, if you are still facing challenges, there are individuals and organizations willing to help you.
Generally, the best source for advice concerning finding coverage for PrEP are people who’ve already successfully obtained coverage themselves. There’s no need to reinvent the wheel. Instead of retreading the same steps, find out where they’ve found success!
Another great source for information and support related to finding insurance coverage is your local HIV, sexual health, or LGBTQ organization. Find them here. Finally, we at the Edmonton Men’s Health Collective (EMHC) can provide some guidance on specific insurance companies which provide coverage for PrEP. You can contact us here.
Brand Name vs. Generic Equivalent: It can cost a lot for a company to bring a new drug onto the market. Some of the costs include research and development, and marketing and promotion for the drug. Because of this, these new brand name drugs can be costly as the company which developed them is aiming to cover these costs and to make a profit. Therefore, governments throughout the world grant patent protection for these products to protect the original manufacturer for a specified number of years. Once the patent expires, other manufacturers are able to produce a generic version of the drug. Generics are expected to have the same dosage, effect, route of administration, and side effects as their brand-name counterparts. However, generic drugs can generally be obtained cheaper as the generic manufacturer does not need to invest the same amount of resources in developing the drug as the original brand-name manufacturer.
Reimbursement: If you have health insurance, your insurance company will reimburse (or cover) part or all the costs of certain medications and health services. In some cases this reimbursement or coverage occurs when paying for a medication or service, while in other cases you may need to pay upfront and submit to your insurance company for reimbursement after-the-fact. In the case that a medication or service is not covered by your insurance company, they are unlikely to reimburse you, meaning that you might have to pay out-of-pocket with your own money.
Indication: An indication is a specific use for a drug. For example, insulin is indicated for (or used to treat) Diabetes. In many cases, a drug might have more than one indication, meaning it can be used to treat multiple health concerns.
Off-Label Prescription: When Health Canada (or in the US, the FDA) approves a drug to be marketed, it approves it for a specific use or uses (or, as per above, indications). For example, Truvada, the brand-name version of TDF/FTC had been approved for the treatment of HIV for some time. In some cases, it is later determined that a drug has other benefits and can be used to treat or address other health needs. In the case of Truvada, it was determined that it was also effective at preventing HIV infection in HIV negative people (i.e. PrEP). Before February 2016, Health Canada had not approved Truvada for use as PrEP, even though the FDA had approved Truvada for use as PrEP in 2012. From the wealth of data, it was apparent that Truvada was both effective and safe to use for preventative purposes.
Because of this, some physicians in Canada began prescribing Truvada as PrEP for their patients long before Health Canada approved it for this use. This means that they were prescribing the drug "off-label." Off-label prescribing is both legal and common. However, there is a greater chance that your insurance company may not provide reimbursement or coverage for drugs that are prescribed off-label.