Long-Acting Injectable ART: Coverage and Cost-Sharing Considerations

ACE TA Center
The HRSA-supported ACE TA Center has released a new fact sheet, Long-Acting Injectable (LAI) Antiretroviral Therapy (ART): Coverage and Cost-Sharing Considerations for Ryan White HIV/AIDS Program (RWHAP) Clients.

LAI ART is a form of HIV treatment that is available as an injection, received routinely by an individual (monthly or bi-monthly), and administered by a clinician or other health care professional. LAI ART may be an option for people with HIV who experience barriers related to adherence to once-daily pill regimens and prefer monthly or bi-monthly injections.

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This new regimen not only requires access to the drug itself, but also to provider/clinician administration of the drug. HIV providers interested in dispensing LAI ART to their patients must learn how to order, receive, and bill for this injectable product, and navigate different billing and payment processes than prescribing oral ART. The procurement and distribution requirements for LAI ART often vary by payer. In addition, public and private payers may treat LAI ART differently than oral medications when it comes to coverage, utilization management, and cost sharing.

The LAI ART: Coverage and Cost-Sharing Considerations for RWHAP Clients fact sheet walks through the different coverage and cost-sharing considerations for LAI ART across public and private payers – including Medicaid, Medicare, and commercial insurance – and provides information to RWHAP recipients and subrecipients so they can help clients navigate access to LAI ART through these different payers. For instance, it can be difficult to determine whether an individual’s insurance covers LAI ART, especially if it is covered as a medical benefit and not listed with other drugs on a plan’s medication formulary. Further, the cost sharing for LAI ART may differ depending on whether the drug is covered as a drug benefit or a medical benefit. The resource also notes where RWHAP recipients may provide assistance to clients in covering the cost sharing associated with LAI ART, for example, assisting with cost sharing for both the drug itself, and with the provider visit and administration of the medication.

LAI ART offers an important opportunity to expand access to HIV treatment, particularly for individuals who may experience barriers with adherence to daily oral regimens which may include, but are certainly not limited to, concerns about confidentiality, safe receipt and storage of medications, and having to take a daily medication. It is important to ensure that RWHAP recipients and the clients they serve are able to navigate health care coverage options to  maximize access to affordable treatment that best fits clients’ needs.

Check out the LAI ART: Coverage and Cost-Sharing Considerations for RWHAP Clients fact sheet.

This blog post was developed by the HRSA-supported ACE TA Center (a project of JSI Research and Training Institute), in collaboration with Killelea Consulting, LLC.