Health care coverage: antiretroviral drugs, drug devices, and drug products

The law bars insurer hurdles for medically necessary HIV prevention treatment and, beginning in 2027, requires coverage of FDA-approved provider-administered options through both medical and pharmacy benefits.

What the law does ​

• Bars health plans and insurers from requiring prior authorization or step therapy for medically necessary HIV-prevention antiretroviral drugs, devices, and products, including PrEP and PEP.
• Allows plans and insurers to require authorization or step therapy for therapeutic equivalents only when at least one equivalent version is available without those requirements.
• Prohibits plans, insurers, and their pharmacy benefit managers from blocking pharmacies or pharmacists from dispensing PrEP or PEP.
• Requires coverage and payment for pharmacist-furnished PrEP or PEP, including pharmacist services and related pharmacist-ordered testing.
• Starting January 1, 2027, requires coverage of FDA-approved non-self-administered HIV-prevention antiretroviral drugs, devices, and products under both medical and prescription drug benefits.
• Requires products obtained through the prescription drug benefit to be dispensed and administered by a licensed health care provider.

Who it affects ​

• People who need medically necessary PrEP, PEP, or other antiretroviral HIV-prevention treatment.
• Health care service plans, health insurers, pharmacy benefit managers, pharmacies, pharmacists, and other licensed health care providers.
• Plans and policies other than limited dental, mental health, vision, Medicare supplement, and specified Medi-Cal managed care coverage.

Context ​

The law applies to health plan contracts and insurance policies, while specified Medi-Cal managed care services remain excluded when their state contracts exclude them.