PrEP Cost Analysis for Covered California Health Plans

CALIFORNIA

HIV/AIDS POLICY

RESEARCH CENTERS

PrEP Cost Analysis

for Covered California

Health Plans

November 2016

AUTHORS

AJ King, MPH

Craig A. Pulsipher, MPP, MSW

Ian W. Holloway, MSW, MPH, PhD

FUNDER

This study was funded by the California HIV/AIDS Research Program (Grant Number RP15–LA–007).

ACKNOWLEDGMENTS

This study was conducted by the California HIV/AIDS Policy Research Center at UCLA/APLA Health, through a generous

grant from the University of California HIV/AIDS Research Program. Additional support was provided by the Center for HIV

Identiﬁcation, Prevention, and Treatment Services NIMH grant P30MH58107. We thank Jennifer Gildner and Sean Beougher

for their assistance with fact checking and copyediting. We also wish to thank Sneha Patil from the San Francisco Department

of Public Health, for her valuable input.

ABOUT THE CALIFORNIA HIV/AIDS RESEARCH PROGRAM

The California HIV/AIDS Research Program fosters outstanding and innovative research that responds to

the needs of all people of California, especially those who are often under served, by accelerating progress

in prevention, education, care, treatment, and a cure for HIV/AIDS. The California HIV/AIDS Research

Program supports two Collaborative HIV/AIDS Policy Research Centers, for research and policy analysis

that addresses critical issues related to HIV/AIDS care and prevention in California. These centers include

the University of California, Los Angeles; APLA Health; Los Angeles LGBT Center; University of California,

San Francisco; San Francisco AIDS Foundation; and Project Inform.

King, AJ, Pulsipher CA, Holloway IW. PrEP Cost Analysis for Covered California Health Plans. November 2016.

Introduction

Open enrollment for Covered California, the State’s health

insurance marketplace, begins November 1, 2016. Before

enrolling, there are important things that you should consider

if you’re HIV-negative and interested in accessing HIV pre-

exposure prophylaxis (PrEP). The purpose of this document

is to help you better understand how much you can expect to

pay for PrEP under various Covered California health plans,

as costs to access PrEP vary by income, area of residence,

and other factors.

About PrEP

PrEP is an HIV prevention strategy in which HIV-negative

individuals take a daily medication to reduce their risk of

becoming infected. Currently, the only drug approved by

the Food and Drug Administration to be used for PrEP is

Truvada

. People who take PrEP are usually required to see

their healthcare provider for routine testing and follow-up

care. Speciﬁcally, according to Clinical Guidelines from the

Centers for Disease Control and Prevention, once PrEP is

initiated, patients should return for follow-up approximately

every 3 months. Not all doctors are familiar with PrEP and

some may resist prescribing it. If you’re interested in PrEP, it’s

important to choose a Covered California plan that ensures

you can ﬁnd a doctor who will prescribe it. Before you make

any ﬁnal decisions, be sure that the primary care doctor you

are considering takes the plan you want and is willing to

prescribe PrEP. A list of doctors with experience providing

PrEP can be found at: www.pleaseprepme.org. A ﬂow chart

offering step-by-step instructions for acquiring PrEP can be

found at www.projectinform.org/pdf/PrEP_Flow_Chart.pdf.

More information about PrEP, including effectiveness and

side effects, can be found at www.prepfacts.org.

Overview of Covered California

The Patient Protection and Affordable Care Act (ACA)

PrEP Cost Analysis

for Covered California

Health Plans

enables individuals and small businesses to purchase health

insurance at federally subsidized rates via statewide health

insurance exchanges like Covered California. Under the

ACA, most individuals who are U.S. citizens, U.S. nationals,

or lawfully present immigrants are required to have health

coverage (there is a tax penalty for those who do not have

health coverage and do not qualify for an exemption). All

eligible Californians can sign up during the annual open-

enrollment period from November 1, 2016 to January 31,

2017. Many others may be eligible to sign up at any time

during the year due to a life-changing event, such as getting

married, having a child, or moving. Medi-Cal enrollment for

those with incomes less than 138% of the federal poverty

level (FPL) ($16,394 for individuals in 2017) is year-round

and also accessible via the Covered California website

[www.coveredca.com].

Health Insurance Plans and Pricing Regions

There are 11 health insurance plans available via

Covered California in 2017:

1. Anthem Blue Cross of California

2. Blue Shield of California

3. Chinese Community Health Plan

4. Health Net

5. Kaiser Permanente

6. L.A. Care Health Plan

7. Molina Healthcare

8. Oscar Health Plan of California

9. Sharp Health Plan

10. Valley Health Plan

11. Western Health Advantage

Under Covered California, the state is comprised of 19

different regions—each with different pricing and health

insurance options, as depicted in Figure 1.

Nearly all Covered California consumers have at least three

health insurance companies to choose from in their region

Figure 1: Covered California Pricing Regions*

respect to which type or types of insurance they provide.

• HMOs are “managed care” and assign a Primary Care

Physician (PCP) to oversee your care. HMOs usually

require members to get a referral from their PCP to see

specialists and HMOs only cover visits to doctors and

hospitals within their plan’s network.

• PPOs are more ﬂexible when choosing doctors and

specialists. PPOs cover doctor visits inside and outside

their networks. However, you pay a higher cost for out-of-

network care.

• EPOs are similar to PPOs because members may not

need a referral to see a specialist. However, EPOs do not

cover visits to doctors outside the plan’s network. Their

network is “exclusive.”

Kaiser and Health Net only cover part of the region

Molina Healthcare only covers part of the region

and in some regions consumers have as many as seven. For

example, if you reside in San Francisco, Pricing Region 4, you

can choose from Anthem, Blue Shield, Chinese Community

Health Plan (CCHP), Kaiser Permanente, Health Net, or

Oscar. In Fresno, Pricing Region 11, you can choose from

Anthem, Blue Shield, Kaiser Permanente, or Health Net.

Los

Angeles County is divided into two pricing regions: 15 and

16. In Pricing Region 16, you can choose from Anthem, Blue

Shield, Kaiser Permanente, Health Net, LA Care, Oscar, or

Molina Healthcare.

There are also three different types of

insurance plans: health maintenance organizations (HMOs),

preferred provider organizations (PPOs), and exclusive

provider organizations (EPOs). Plans vary by region with

1. Northern counties

2. North Bay Area

3. Greater Sacramento

4. San Francisco County

5. Contra Costa County

6. Alameda County

7. Santa Clara County

8. San Mateo County

9. Santa Cruz, San Benito,

Monterey

10. Central Valley

11. Fresno, Kings, Madera

Counties

12. Central Coast

13. Eastern Counties

14. Kern County

15. Los Angeles County

(partial)

16. Los Angeles County

(partial)

17. Inland Empire

18. Orange County

19. San Diego County

* Portions of this section were

drawn directly from the Covered

California website [coveredca.org]

The Metal-Category System

Covered California health insurance plans are sold in four

levels of coverage or metal categories: Bronze, Silver,

Gold, and Platinum. As the metal category increases in

value (from Bronze to Platinum), so does the percentage

of medical expenses that a health insurance plan covers

relative to what you are expected to pay in copays and

deductibles. Typically, Platinum plans cover 90% of health

care costs, while you pay 10%; Gold plans cover 80%,

while you pay 20%; Silver plans cover 70%, while you

pay 30%; and Bronze plans cover 60%, while you pay

40%. Plans in higher metal categories have higher monthly

premiums, but when you need medical care you pay less.

You can choose to pay a lower monthly premium, but when

you need medical care you pay more. When deciding

which level of coverage best meets your health needs and

budget, note: If you are interested in accessing PrEP,

Bronze plans should generally be avoided. Despite

their low premiums, they have high deductibles and out-

of-pocket costs that are likely to make accessing some

medications and beneﬁts unaffordable. It's very important,

however, to consider both out-of-pocket costs and monthly

premiums before you select a health plan.

Drug Formularies and Tiers

Each health insurance company has a list of covered

medications, known as a drug formulary. It is important

to remember that a plan’s drug formulary can change

at any time and the plan will have the most up-to-date

formulary. Drugs on the formulary are grouped into four

tiers: generic (Tier 1), preferred (Tier 2), non-preferred

(Tier 3), or specialty (Tier 4). On Covered California you

will be charged no more than $250 per month for one 30-

day supply of a Tier 4, specialty drug for Silver, Gold, and

Platinum plans and no more than $500 per 30-day supply

for Bronze plans. Drugs in lower tiers will have lower costs.

Truvada

is currently covered by all Covered California

health plans and is listed as a Tier 2, preferred drug.

Standard Beneﬁts

All health insurance plans sold through Covered California

have standard beneﬁts, including coverage for prescription

drugs, doctor visits, hospitalizations, labs, and mental

health and substance abuse services. Differences in

these standard beneﬁts help consumers compare health

insurance options. It is important to review each plan’s

price, provider network, “Summary of Beneﬁts and

Coverage,” as well as more detailed coverage descriptions,

to ﬁnd the plan that best suits your needs.

Overview of Costs Associated with Healthcare

There are two cost categories related to having health

insurance and accessing care: monthly premiums (minus

premium assistance, if applicable); and “out of pocket”

costs (minus any cost-sharing subsidies, if applicable).

Monthly Premiums and Premium Assistance

Monthly premiums are the price you pay for having health

insurance, regardless of whether you use it. If your income

is less than or equal to 400% FPL, or $47,520 for a

single person, you may qualify for help paying for your

health insurance premium, regardless of the metal level

you choose. This is known as premium assistance or the

federal government’s “advance premium tax credit.” You

can choose to receive this assistance in one of two ways:

1) as an advance each month, which lowers your monthly

payments, or 2) at the end of the year when you complete

your taxes. The amount you pay in monthly premiums will

vary depending on:

• your age (the older you are, the more expensive health

insurance is);

• your region (typically, if you live in Northern California

you will pay more for health insurance than if you live in

Southern California);

• your income (given that you can get premium

assistance if your income is less than or equal to 400%

FPL, as described above);

• the metal level you choose (you will pay the highest

premiums for Platinum level, followed by Gold, then

Silver, then Bronze).

Covered California recently announced average premium

increases of 13.2 percent for 2017, so it is very important

for consumers to shop to ﬁnd a plan that best meets their

health needs and budget.

Out-of-Pocket Costs and Cost-Sharing Subsidies

Out-of-pocket costs include an annual deductible, if

applicable, and copays or coinsurance for medications,

lab tests, doctor visits, and hospital stays. If your income

is less than or equal to 250% FPL, or $29,700 for a

single person, you may qualify for cost-sharing subsidies,

which reduce your out-of-pocket costs including copays,

coinsurance and deductibles. They may also reduce your

out-of-pocket maximum. Cost-sharing subsidies are

only available if you select a Silver plan – known as

Enhanced Silver plan. There are three categories of

Enhanced Silver – Silver 73, Silver 87, Silver 94.

For single households, if you make:

• between 139-150% FPL ($16,395 - $17,820), you can

qualify for a Silver 94 plan

• between 151-200% FPL ($17,821 - $23,760), you can

qualify for a Silver 87 plan

• between 201-250% FPL ($23,761 - $29,700), you can

qualify for a Silver 73 plan

Drug deductibles and copays are lower for the Silver 94,

87, and 73 than the Silver 70 (basic Silver plan without

enhancements) because costs are subsidized for lower

income individuals to make the plan affordable based on

income.

Out-of-Pocket Maximum

The out-of-pocket maximum is the most you would have

to pay for medical expenses during the year (not including

your monthly premiums). Keep in mind that out-of-pocket

maximums differ depending on your income and which

metal level you select. Deductibles, copays and coinsurance

count toward your out-of-pocket maximum unless they are

considered “out of network” or “not covered.” In most cases,

once you reach your out-of-pocket maximum, your insurance

will cover 100% of the costs they consider medically

necessary. It’s important to understand what out-of- pocket

costs will count toward your out-of-pocket maximum before

signing up for a new health plan.

To summarize, the amount you pay in “out-of-pocket” costs (in

addition to your monthly premium) will vary depending on:

• the amount and type of health services and prescription

medication you access;

• your income (you are eligible for cost sharing subsidies if

your income is between 138% -250% FPL);

• the metal level you choose (highest out-of-pocket costs

for Bronze level);

• your annual deductible;

• your out-of-pocket maximum.

Determining PrEP Costs

The costs associated with taking PrEP include:

1. the cost of medication (Truvada

);

2. the cost of doctor visits;

3. the cost of laboratory tests your doctor orders;

4. the cost of health insurance (i.e., your monthly premiums).

Estimating the cost of Truvada

Without insurance, Truvada

costs approximately $1,250

monthly or $15,000 annually. However, under Covered

California plans, the cost you pay will be much less and

depends on your plan’s drug formulary and the metal

level you choose. Across all Covered California plans,

Truvada

is listed as a Tier 2 or preferred drug. Gilead, the

company that manufactures Truvada

, offers a copay card

to help cover the cost of the medication for those who

have insurance – up to $3,600 a year. Table 1 depicts the

annual cost of Truvada

by metal level with and without

the Gilead copay card. These costs were calculated

using information from Covered California’s 2017 Patient-

Centered Beneﬁt Designs and Medical Cost Shares. A

12-month supply of Truvada

ranges from $120 - $6,000

without the Gilead copay card, and from $0 - $2,400 with

the Gilead copay card, depending on the metal level you

choose. Information about the copay program can be found

at www.gileadcopay.com. You may also be able to obtain

ﬁnancial assistance from the Patient Access Network at

www.panfoundation.org/fundingapplication/welcome.php

or the Patient Advocate Foundation at www.copays.org/

diseases/hiv-aids-and-prevention.

California’s PrEP Financial Assistance Program

In spring 2017, the California Department of Public Health,

Ofﬁce of AIDS will launch a PrEP ﬁnancial assistance

program. The program will cover PrEP-related out-of-

pocket costs (e.g., copays for medication, doctor visits,

and laboratory tests) for qualiﬁed individuals with annual

incomes below 500% FPL.

Estimating additional out-of-pocket costs

and monthly premiums

Additional out-of-pocket costs for PrEP, including doctor

visits, laboratory tests, as well as deductibles and out-

of-pocket maximums, are summarized by metal level in

Table 2. Cost estimates include ﬁve doctor visits and ﬁve

labs during the ﬁrst year of PrEP initiation to account

for the initial visit, a one-month follow-up visit, and then

three additional follow-up visits every three months for the

duration of the year. Additionally, out-of-pocket maximums

may vary from plan to plan with respect to whether they

include deductibles. For our cost estimations, we assume

that deductibles count towards out-of-pocket maximums.

In our calculations, we assume a primary care visit costs

$200. Out-of-pocket costs may be more if you are required

to see a specialist.

As described above, monthly premiums vary signiﬁcantly

based on a number of factors. To illustrate this point, Table

3 lists the monthly premiums for health plans available in

Los Angeles, San Francisco, and Fresno, by metal level, for

different ages. These premiums don’t include all options

under each plan (e.g. EPOs and PPOs were not included if

an HMO was also available). These premiums also do not

include any premium assistance or tax savings, given they

Covered California

Metal Levels

Truvada

Cost How Cost was Calculated

Without Gilead

co-pay card

With Gilead

co-pay card

Bronze $6,000 $2,400

$500 pharmacy deductible

Full cost up to $500 after drug deductible is met:

1st month: $500 (deductible met)

2nd – 12th month: $500/month = $5,500

Silver $855 $0

$250 pharmacy deductible

$55 copay/month:

1st month: $250 (deductible met)

2nd – 12th month: $55/month = $605

Silver - Enhanced 73* $800 $0

$250 pharmacy deductible

$50 copay/month:

1st month: $250 (deductible met)

2nd – 12th month: $50/month = $550

Silver - Enhanced 87* $270 $0

$50 pharmacy deductible

$20 copay/month:

1st month: $50 (deductible is met)

2nd – 12th month: $20/month = $220

Silver - Enhanced 94* $120 $0

No deductible

$10 copay/month:

1st – 12th month: $10/month = $120

Gold $660 $0

No deductible

$55 copay/month:

1st – 12th month: $55/month = $660

Platinum $180 $0

No deductible

$15 copay/month:

1st – 12th month: $15/month = $180

*These metal levels have the cost-sharing subsidies built in.

were calculated for individuals with incomes above 400%

FPL or $47,520 for a single person. Finally, Tables 4, 5,

and 6 estimate the total costs (out-of-pocket costs and

monthly premiums) associated with accessing PrEP via

Covered California for ﬁctitious individuals of different ages

and incomes living in different regions of California. Table 7

demonstrates how those costs were calculated.

Selecting the best Covered California health plan to meet

your overall healthcare needs can be challenging. Certiﬁed

Enrollment Counselors and Insurance Agents, as well

as Covered California Call Center representatives, are

available to answer questions about ﬁnancial assistance

and can help you compare plans. You can ﬁnd free,

conﬁdential, in-person help at http://www.coveredca.com/

get-help/local/.

Table 1: Summary of Annual Truvada

Costs by Metal Level

Covered California

2017 Metal Levels

Estimated Annual Cost

of Truvada

Cost of Care Accessed

(5 doctor visits and 5 labs

per year)

Estimated Annual

OOP Costs

Bronze

Max OOP

: $6,800

$6,000

(with Gilead copay card: $2400)

Primary Care

Visits:

$75 for ﬁrst 3 visits and full

cost for 4th and 5th visits until

deductible is met = $225 +

(~$200 x 2) = $625

6000

625

+200

$6,825

OOP MAX = $6,800

($3,200 with Gilead copay card)

Laboratory Tests:

$40 x 5 per year = $200

Silver 70

Available for individuals with

income above $29,701

(≥251% FPL)

Max OPP: $6,800

$855

(with Gilead copay card: $0)

Primary Care Visits:

$35 x 5 = $175

855

175

+175

$1,205

($350 with Gilead copay card)

Laboratory Tests:

$35 x 5 per year = $175

Silver 73

For individuals with income

$23,761-$29,700

(>200% to ≤250% FPL)

Max OOP: $5,700

$800

(with Gilead copay card: $0)

Primary Care Visits:

$30 x 5 = $150

800

150

+175

$1,125

($325 with Gilead copay card)

Laboratory Tests:

$35 x 5 per year = $175

Silver 87

For individuals with income

$17,821-$23,760

(>150% to ≤200% FPL)

Max OOP: $2,350

$270

(with Gilead copay card: $0)

Primary Care Visits:

$10 x 5 = $50

270

+75

$395

($125 with Gilead copay card)

Laboratory Tests:

$15 x 5 per year = $75

Silver 94

For individuals with incomes up

to $17,820 (150% FPL)

Max OPP: $2,350

$120

(with Gilead copay card: $0)

Primary Care Visits:

$5 x 5 = $25

120

+40

$185

($65 with Gilead copay card)

Laboratory Tests:

$8 x 5 per year = $40

Table 2: Summary of Estimated Out-of-Pocket (OOP) Costs for PrEP by Metal Level

Max OOP refers to the maximum amount you’ll have to pay during a policy period for health services (usually a year).

Once you reach your Max OPP your plan begins to pay 100 percent of the covered services.

Specialist visits may be slightly higher

Covered California

2017 Metal Levels

Estimated Annual Cost

of Truvada

Cost of Care Accessed

(5 doctor visits and 5 labs

per year)

Estimated Annual

OOP Costs

Gold

Max OOP: $6,750

$660

(with Gilead copay card: $0)

Primary Care Visits:

$30 x 5 = $150

660

150

+175

$985

($325 with Gilead copay card)

Laboratory Tests:

$35 x 5 per year = $175

Platinum

Max OOP: $4,000

$180

(with Gilead copay card: $0)

Primary Care Visits:

$15 x 5 = $75

180

+100

$355

($175 with Gilead copay card)

Laboratory Tests:

$20 x 5 per year = $100

Range Across Plans

$120-$6,000

($0-$2,400 with Gilead

copay card)

$185-$6,800

($65 - $3,200 with

Gilead copay card)

Table 2: Summary of Estimated Out-of-Pocket (OOP) Costs for PrEP by Metal Level (cont’d.)

CCHP Oscar Kaiser Blue Shield

SF SF LA SF LA Fresno SF LA Fresno

Bronze

Age 20 $156 $185 $127 $160 $121 $123 $204 $161 $137

Age 30 $279 $330 $227 $286 $216 $221 $354 $288 $245

Age 40 $314 $372 $256 $322 $243 $248 $411 $324 $276

Age 50 $438 $519 $357 $450 $340 $347 $575 $453 $385

Silver 70

Age 20 $202 $240 $165 $221 $167 $170 $247 $178 $161

Age 30 $361 $429 $295 $394 $298 $304 $441 $318 $288

Age 40 $407 $483 $332 $444 $335 $342 $497 $358 $324

Age 50 $569 $675 $465 $620 $469 $479 $694 $501 $453

Gold

Age 20 $250 $278 $191 $256 $193 $197 $299 $216 $200

Age 30 $445 $497 $342 $457 $345 $352 $535 $386 $358

Age 40 $502 $560 $385 $514 $389 $397 $602 $434 $403

Age 50 $701 $782 $538 $719 $453 $555 $842 $607 $563

Platinum

Age 20 $275 $316 $217 $282 $213 $218 $370 $267 $256

Age 30 $491 $565 $389 $504 $381 $389 $661 $477 $458

Age 40 $553 $636 $438 $568 $429 $438 $744 $537 $515

Age 50 $773 $888 $611 $794 $600 $612 $1,040 $750 $720

Table 3: Monthly Premiums for Individuals with incomes above 400% FPL in San Francisco, Los Angeles,

and Fresno

Anthem Blue Health Net Molina LA Care

SF LA Fresno SF LA Fresno LA LA

Bronze

Age 20 $190 $147 $125 $203 $154 $167 $100 $120

Age 30 $340 $263 $223 $364 $275 $299 $178 $215

Age 40 $382 $296 $251 $409 $310 $337 $201 $242

Age 50 $534 $414 $351 $572 $433 $470 $280 $338

Silver 70

Age 20 $270 $150 $205 $270 $144 $222 $127 $134

Age 30 $482 $268 $366 $482 $257 $397 $227 $240

Age 40 $543 $302 $412 $543 $289 $447 $256 $270

Age 50 $759 $422 $575 $759 $404 $624 $358 $378

Gold

Age 20 $341 $184 $250 $336 $181 $277 $143 $158

Age 30 $610 $328 $447 $601 $324 $495 $255 $283

Age 40 $686 $370 $504 $677 $364 $557 $287 $319

Age 50 $959 $517 $704 $946 $509 $778 $401 $445

Platinum

Age 20 $406 $221 $301 $397 $201 $327 $165 $184

Age 30 $725 $395 $539 $710 $359 $584 $295 $329

Age 40 $816 $445 $607 $800 $404 $658 $332 $370

Age 50 $1,141 $622 $848 $1,118 $564 $919 $464 $518

Table 3: Estimated monthly premiums for individuals with incomes above 400% FPL in San Francisco,

Los Angeles, and Fresno (cont’d.)

Table 4: Estimated costs to access PrEP for a 25 year-old individual with an income of $17,820 (150% FPL)

in Los Angeles

BRONZE

Molina LA Care Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

x 12 = $72

$38

x 12 = $456

$92 HSP

x 12 = $1,104

$81 EPO

x 12 = $972

$49 EPO

x 12 = $588

$39

x 12 = $468

$103 PPO

x 12 = $1,236

Doctor Visits 1st 3 @ $75, then full cost (~$200) until deductible is met = $625

Labs $40/per x 5 = $200

Truvada

Full cost up to $500/mo. after $500 deductible is met = $6,000

Deductible $6,300 medical/ $500 pharmacy

OOP Max $6,800

TOTAL COST

(w/Gilead

copay card )

$6,872

($3,272)

$7,256

($3,656)

$7,904

($4,304)

$7,772

($4,172)

$7,388

($3,788)

$7,268

($3,668)

$8,036

($4,436)

SILVER 94

Molina LA Care Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$49

x 12 = $588

$60

x 12 = $720

$75

x 12 = $900

$85 HMO

x 12 = $1,020

$178 EPO

x 12 = $2,136

$109

x 12 = $1,308

$111

x 12 = $1,332

$129 HMO

x 12 = $1,548

$147 PPO

x 12 = $1,764

Doctor Visits $5/per x 5 = $25

Labs $8/per x 5 = $40

Truvada

$10/per x 12 = $120

Deductible $75/$0

OOP Max $2,350

TOTAL COST

(w/Gilead

copay card )

$773

($653)

$905

($785)

$1,085

($965)

$1,205

($1,085)

$2,321

($2,201)

$1,493

($1,373)

$1,517

($1,397)

$1,733

($1,613)

$1,949

($1,829)

Premium reﬂects a tax credit (i.e. ﬁnancial assistance)

GOLD

Molina LA Care Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$74

x 12 = $888

$98

x 12 = $1,176

$134

x 12 = $1,608

$138 HMO

x 12 = $1,656

$266 EPO

x 12 = $3,192

$151 EPO

x 12 = $1,812

$153

x 12 = $1,836

$189 HMO

x 12 = $2,268

$220 PPO

x 12 = $2,640

Doctor Visits $30/per x 5 = $150

Labs $35/per x 5 = $175

Truvada

$55 x 12 = $660

Deductible $0/$0

OOP Max $6,750

TOTAL COST

(w/Gilead

copay card )

$1,873

($1,213)

$2,161

($1,501)

$2,593

($1,933)

$2,641

($1,981)

$4,177

($3,517)

$2,797

($2,137)

$2,821

($2,161)

$3,253

($2,593)

$3,625

($2,965)

PLATINUM

Molina LA Care Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$109

x 12 = $1,308

$139

x 12 = $1,668

$165

x 12 = $1,980

$198 HMO

x 12 = $2,376

$345 EPO

x 12 = $4,140

$192 EPO

x 12 = $2,304

$185

x 12 = $2,220

$270 HMO

x 12 = $3,240

$324 PPO

x 12 = $3,888

Doctor Visits $15/per x 5 = $75

Labs $20/per x 5 = $100

Truvada

$15 x 12 = $180

Deductible $0/$0

OOP Max $4,000

TOTAL COST

(w/Gilead

copay card )

$1,663

($1,483)

$2,023

($1,843)

$2,335

($2,155)

$2,731

($2,551) or

$4,495

($4,315)

$2,659

($2,479)

$2,575

($2,395)

$3,595

($3,415) or

$4,243

($4,063)

Table 4: Estimated costs to access PrEP for a 25 year-old individual with an income of $17,820 (150% FPL)

in Los Angeles (con’t.)

Table 5: Estimated costs to access PrEP for a 40 year-old individual with an income of $29,700 (250% FPL)

in San Francisco

BRONZE

CCHP Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$74

x 12 = $888

$169 EPO

x 12 = $2,028

$142 EPO

x 12 = $1,704

$132 EPO

x 12 = $1,584

$82

x 12 = $984

$171 PPO

x 12 = $2,052

Doctor Visits 1st 3 @ $75, then full cost (~$200) until deductible is met = $625

Labs $40/per x 5 = $200

Truvada

Full cost up to $500/mo. after $500 deductible is met = $6,000

Deductible $6,300/$500

OOP Max $6,800

TOTAL COST

(w/Gilead co-

pay card )

$7,688

($4,088)

$8,828

($5,228)

$8,504

($4,904)

$8,384

($4,784)

$ 7,78 4

($4,184)

$8,852

($5,252)

SILVER 73

CCHP Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$167

x 12 = $2,004

$303 EPO

x 12 = $3,636

$303 EPO

x 12 = $3,636

$243 EPO

x 12 = $2,916

$204

x 12 = $2,448

$257 HMO

x 12 = $3,084

$244 PPO

x 12 = $2,928

Doctor Visits $30/per x 5 = $150

Labs $35/per x 5 = $175

Truvada

$50/per after deductible = $800

Deductible $2200/$250

OOP Max $5,700

TOTAL COST

(w/Gilead co-

pay card )

$3,129

($2,329)

$4,761

($3,961)

$4,761

($3,961)

$4,041

($3,241)

$3,573

($2,773)

$4,209

($3,409)

$4,053

($3,253)

Premium reﬂects a tax credit (i.e. ﬁnancial asssitance)

GOLD 80

CCHP Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$262

x 12 = $3,144

$437 EPO

x 12 = $5,244

$446 EPO

x 12 = $5,352

$320 EPO

x 12 = $3,840

$274

x 12 = $3,288

$362 HMO

x 12 = $4,344

$361 PPO

x 12 = $4,332

Doctor Visits $30/per x 5 = $150

Labs $35/per x 5 = $175

Truvada

$55 x 12 = $660

Deductible $0/$0

OOP Max $6750

TOTAL COST

(w/Gilead co-

pay card )

$4,129

($3,469)

$6,229

($5,569)

$6,337

($5,677)

$4,825

($4,165)

$4,273

($3,613)

$5,329

($4,669) or

$5,317

($4,657)

PLATINUM

CCHP Health Net Anthem Blue Oscar Kaiser Blue Shield

Monthly

Premium

$313

x 12 = $3,756

$560 EPO

x 12 = $6,720

$576 EPO

x 12 = $6,912

$396 EPO

x 12 = $4,752

$328

x 12 = $3,936

$504 HMO

x 12 = $6,048

$529 PPO

x 12 = $6,348

Doctor Visits $15/per x 5 = $75

Labs $20/per x 5 = $100

Truvada

$15 x 12 = $180

Deductible $0/$0

OOP Max $4,000

TOTAL COST

(w/Gilead co-

pay card )

$4,111

($3,931)

$7,075

($6,895)

$7,267

($7,087)

$5,107

($4,927)

$4,291

($4,111)

$6,403

($6,223) or

$6,703

($6,523)

Table 5: Estimated costs to access PrEP for a 40 year-old individual with an income of $29,700 (250% FPL)

in San Francisco (con’t.)

Table 6: Estimated costs to access PrEP for a 50 year-old individual with an income of $47,520 (400% FPL)

in Fresno

BRONZE

Health Net Anthem Blue Kaiser Blue Shield

Monthly

Premium

$378

x 12 = $4,536

$258 (PPO)

x 12 = $3,096

$254

x 12 = $3,048

$292 (PPO)

x 12 = $3,504

Doctor Visits 1st 3 @ $75, then full cost (~$200) until deductible is met = $625

Labs $40/per x 5 = $200

Truvada

Full cost up to $500/mo. after $500 deductible is met = $6,000

Deductible $6,300/$500

OOP Max $6,800

TOTAL COST

(w/Gilead copay card )

$11,336

($7,736)

$9,896

($6,296)

$9,848

($6,248)

$10,304

($6,704)

SILVER 70

Health Net Anthem Blue Kaiser Blue Shield

Monthly

Premium

$531

x 12 = $6,372

$482

x 12 = $5,784

$406 (PPO)

x 12 = $4,872

$386

x 12 = $4,632

$360 (PPO)

x 12 = $4,320

Doctor Visits $35/per x 5 = $175

Labs $35/per x 5 = $175

Truvada

$55/per after deductible = $855

Deductible $2,500/$250

OOP Max $6,800

TOTAL COST

(w/Gilead copay card )

$7,577

($6,722)

$6,989

($6,184)

$6,077

($5,222)

$5,837

($4,982)

$5,525

($4,670)

Table 6: Estimated costs to access PrEP for a 50 year-old individual with an income of $47,520 (400% FPL)

in Fresno (cont'd)

GOLD 80

Health Net Anthem Blue Kaiser Blue Shield

Monthly

Premium

$685

x 12 = $8,220

$611

x 12 = $7,332

537 (PPO)

x 12 = $6,444

$462

x 12 = $5,544

$470 (PPO)

x 12 = $5,640

Doctor Visits $30/per x 5 = $150

Labs $35/per x 5 = 175

Truvada

$55 x 12 = $660

Deductible $0/$0

OOP Max $6,750

TOTAL COST

(w/Gilead copay card )

$9,205

($8,545)

$8,317

($7,657) or

$7,429

($6,769)

$6,529

($5,869)

$6,625

($5,965)

PLATINUM

Health Net Anthem Blue Kaiser Blue Shield

Monthly

Premium

$826

x 12 = $9,912

$755

x 12 = $9,060

$657 (PPO)

x 12 = $7,884

$519

x 12 = $6,228

$627 (PPO)

x 12 = $7,524

Doctor Visits $15/per x 5 = $75

Labs $20/per x 5 = $100

Truvada

$15 x 12 = $180

Deductible $0/$0

OOP Max $4,000

TOTAL COST

(w/Gilead copay card )

$10,267

($10,087)

$9,415

($9,235) or

$8,239

($8,059)

$6,583

($6,403)

$7,879

($7,699)

Table 7: Example of Cost Breakdown for Molina Healthcare Bronze Level Plan in Los Angeles

Monthly

Premium

Doctor

Visit

Lab Truvada

Total Spent

by Consumer

Cumulative

Total Spent

“OOP”

Amount

Applied

Toward Drug

Deductible/

Mo.

Cumulative

Amount

Applied

Toward Med.

Deductible/

Without

copay card

With

copay card

Without

copay card

With

copay card

Jan. $6 $75 $40 $500 $200 $621 $321 $615 $500: MET $115

Feb. $6 $75 $40 $500 $200 $621 $321 $1,230 — $230

March $6 — — $500 $200 $506 $206 $1,730 — $230

April $6 — — $500 $200 $506 $206 $2,230 — $230

May $6 $75 $40 $500 $200 $621 $321 $2,845 — $345

June $6 — — $500 $200 $506 $206 $3,345 — $345

July $6 — — $500 $200 $506 $206 $3,845 — $345

August $6 $200 $40 $500 $200 $746 $446 $4,585 — $585

Sept. $6 — — $500 $200 $506 $206 $5,085 — $585

Oct. $6 — — $500 $200 $506 $206 $5,585 — $585

Nov. $6 $200 $40 $500 $200 $746 $446 $6,329 — $825

Dec. $6 — —

$475

+$25*

$171

+$29*

$481 $181

$6,800

OPP MAX

MET

— —

Total $72 $625 $200 $6,000 $2,400 $6,872 $3,272 $6,800 — $825

* Paid for by plan after OOP maximum is reached

Glossary

Premium

The amount you pay every month for your health insurance

plan.

Deductible

The amount you pay before the health plan begins to pay.

Plans can have different deductibles – one for medical costs

like doctor visits or lab work and another one for drugs, or

they can combine the two.

Copay

A ﬁxed amount you pay for services until you reach the out-

of-pocket maximum. For example, you might pay $20 for a

doctor visit and $40 for an x-ray.

Coinsurance

A ﬁxed percentage of the cost of the service that you pay

until you reach your out-of-pocket maximum. For example,

you might pay 30% of the cost of your lab test. Coinsurance

can make it difﬁcult to determine the exact amount of out-

of-pocket cost as it is extremely difﬁcult to ﬁnd the cost of a

particular service.

Out-of-Pocket Maximum

The most you have to pay for medical expenses during the

year above and beyond your monthly premium. Depending on

your plan, these expenses may include an annual deductible,

co-insurance and co-pays for doctor visits, lab tests, and

prescription drugs. Deductibles, co-pays, and co-insurance

count toward your out-of-pocket maximum unless they are

considered “out of network” or “not covered.” Premiums do

not count. In most cases, once you reach your out-of-pocket

maximum, your insurance will cover 100% of the costs they

consider medically necessary.

Formulary

The set of prescription drugs covered by a health insurance

plan. Drugs on the formulary are grouped into four tiers:

generic (Tier 1), preferred (Tier 2), non-preferred (Tier 3), or

specialty (Tier 4).

References

This report was compiled from information obtained via the

Covered California website (http://www.coveredca.com) and

Project Inform’s “How to choose a health plan in Covered

California” (http://www.projectinform.org/pdf/CCguide.pdf).