S.3227.A/A.6059 – PrEP No Prior Authorization

This legislation, S.3227-A/A.6059, would prohibit prior authorization for coverage for pre-exposure prophylaxis (PrEP) used to prevent HIV infection. The New York Health Plan Association (HPA) opposes this legislation, as restrictions on prior authorization undercut health plan efforts to promote safe, coordinated health care that will increase the cost of coverage for consumers, employers, and the state. This bill is also unnecessary as protections already exist to ensure patients have appropriate access to PrEP.

Health plans support and promote the use of evidence-based, best practices. However, these measures evolve and change over time. One way that health plans seek to ensure that patients have access to the most clinically appropriate and cost-effective services and medications is through prior authorization policies.  Prior authorization policies help health plans to ensure that care is delivered in the most appropriate setting and that services are evidence-based, particularly in areas where there is wide variation in practice and gaps between what the clinical evidence shows and care patients receive.

Prior authorization is an important tool to protect patients from unnecessary and potentially harmful care. For example, it is utilized to help ensure that medications are safe, effective, and provide value for specific populations or subpopulations who may be affected differently by a medication, and to make sure that a medication is not co-prescribed with another medication that could have dangerous interactions. A key component of the provision of PrEP is ensuring it is only provided to HIV negative individuals, confirmed through routine HIV testing.  For PrEP, prior authorization is necessary to ensure that patients have been tested for HIV, do not have symptoms consistent with acute viral infection that would require other therapies, and have access to counseling on HIV infection risk reduction.

Additionally, it ensures that the clinician providing the care has the appropriate training to deliver the care being requested. Further, prior authorization enables health plans to improve care coordination by making sure care management supports are in place as members navigate the system and help with follow-up care and other services that help the member succeed in recovery. Prohibiting the use of prior authorization would remove critical protections for patients and undercut efforts to ensure that the care they receive is safe, affordable and effective.

When developing prior authorization policies, health plans review information on the use of inappropriate treatments, practice variation for specific services, the extent to which providers deliver care consistent with evidence, safety concerns, and other relevant factors to determine what services or drugs should be subject to prior authorization. Health plans regularly review the medical services and prescription drugs that are subject to prior authorization and make changes based on new evidence, adherence to recognized standards of care, or, in the case of new and emerging therapies, limited available evidence or safety concerns. These reviews are conducted by Pharmacy and Therapeutics committees with relevant clinical expertise.

State measures already exist to protect patients, making S.3227-A/A.6059 unnecessary. In December 2017, the Department of Financial Services (DFS) issued a circular letter reminding health plans that prior authorization requirements cannot create an unacceptable barrier to coverage for individuals who would otherwise benefit from PrEP. In its circular letter, DFS noted the requirement that health plans must provide coverage for PrEP, and that in making coverage determinations they must do so in a non-discriminatory manner and that they “use appropriate written clinical review criteria when reviewing for medical necessity.”  Last year, the Legislature passed A.807/S.688 requiring coverage of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), which the Governor signed as Chapter 721 of the Laws of 2022.  This requirement is in effect today, ensuring patients have access to these medications as needed.

For all these reasons, HPA OPPOSES S.3227-A/A.6059.