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.
Who is eligible to prescribe publicly funded PrEP?
In order for a patient to access PrEP that is funded by 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.
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 your patient is unable to access public coverage for PrEP, they will likely have to consider paying out-of-pocket or attempting to obtain coverage through their private insurance plan. Fortunately, with generic versions of PrEP now available on the Canadian market, they 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. Prices can change with little or no notice and may differ between different pharmacies. If you or your patient are aware of a price change that is not reflected on this website, please contact us 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 Your Patients?
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 to help those in your care understand what they can expect to pay for PrEP as well as some practical steps they might need to take to successfully obtain coverage through their insurance provider.
How much PrEP will actually cost an individual depends on a few different things:
How much they pay for insurance and whether or not they’re obtaining insurance solely to cover PrEP
What portion of their PrEP prescription is covered by their insurance policy vs. how much they’re expected to pay out-of-pocket (as their co-pay)
Whether their insurance policy has an annual limit and whether their PrEP prescription (in combination with their other prescriptions) surpasses that limit, meaning they will need to pay the remainder.
To better illustrate how these elements can affect how much someone might pay for PrEP, here are a couple of examples (prices based on max markup and dispensing fees):
Scenario No. 1: Insurance provides no coverage and patient pays 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: Individual purchases insurance solely for PrEP coverage. It costs them $100 per month. It covers 80% of their 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 they 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: The individual already has and would maintain prescription drug coverage regardless of accessing PrEP and therefore doesn’t factor their insurance premium into the overall cost of PrEP. Their plan covers 70% up to a total of $10,000. Their plan will only reimburse for Truvada and none 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:
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.
An individual should consider all of the various elements of their current or prospective plan that will contribute to cost (premium, co-pay, and annual limit).
Different PrEP options will become cheaper or more expensive depending on which options their insurance plan does or doesn’t cover.
Navigating the Coverage Pathway
[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 human resources department or directly with their policy provider to find out details of their coverage. 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. An individual should follow-up with the insurer directly to find out if there are any further stipulations to coverage related to the TDF/FTC.
Documents Someone Might Need
Drug Special Authorization or Exception Form
If an individual’s policy does not generally cover TDF/FTC or does not commonly cover it for use as PrEP, their insurance company might require a form to be filled out by their provider explaining why they are being prescribed the drug and why it should be covered under their insurance policy. The individual should check with their insurance provider to see if they have a standard form.
Access Navigation Support
If an individual continues to have challenges accessing coverage for PrEP, they can find information and support from their 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.