PrEP and PEP Coverage Mandated at Zero Cost Across All Major Health Plans, Starting Next Year

The new “PrEP and PEP are Prevention Act” is a major move to eliminate financial barriers to HIV prevention. Simply put, this bill mandates that nearly every major health plan—from private insurance to Medicare, Medicaid, and plans for federal employees—must cover HIV prevention services, including the medications PrEP and PEP, at absolutely zero cost to the patient. No copays, no deductibles, no coinsurance. If you need these drugs, or the tests and counseling that go with them, your wallet stays closed. This change is set to roll out starting with the first plan year after the law is enacted, with Medicare and Medicaid changes kicking in on January 1st of the following calendar year.

No More Sticker Shock for Prevention

This legislation is designed to take the guesswork and the cost out of highly effective preventive care. For those with private insurance, the bill adds FDA-approved HIV prevention drugs (like PrEP and PEP), along with necessary lab tests, counseling, and clinical follow-up, to the list of services that must be covered with no out-of-pocket costs, according to Section 2713(a) of the Public Health Service Act. For a busy person who needs PrEP, this means the monthly cost for the medication and the required quarterly blood work goes from potentially hundreds of dollars to zero. The bill also clamps down on prior authorization, generally prohibiting insurers from requiring pre-approval. There is one small exception: they can require prior authorization for a specific brand-name drug if they already cover a therapeutically equivalent drug without needing pre-approval first. This is a common insurance tactic that could nudge patients toward generics or specific brands, but the overall goal is clear: make prevention easy and free.

Medicare and Medicaid Get a Major Update

If you or a family member rely on public health programs, the cost relief is just as comprehensive. For Medicare Part B (outpatient services), the bill explicitly waives the standard deductible and coinsurance for all defined HIV prevention services starting January 1st after enactment. This is huge because Part B usually requires a 20% coinsurance payment. For Medicare Part D (prescription drugs), PrEP and PEP drugs are completely exempt from deductibles and all cost-sharing. Think of a senior or a person with a disability on Medicare who needs PrEP—this bill ensures they pay nothing for the medication.

Medicaid and CHIP (Children's Health Insurance Program) are similarly mandated to cover these services without any cost-sharing. This is critical for low-income families and individuals, ensuring that states can’t charge copayments or deductibles for these specific preventive measures. While states that need new legislation get a little extra time to comply, the mandate is clear: zero cost for prevention for their most vulnerable populations. This standardization across all major federal programs is a massive step toward health equity.

The Real-World Impact and Fine Print

For everyday people, this bill removes a significant barrier to public health. If you are a young professional considering PrEP, the cost of the drug and the required lab work is often the biggest hurdle. This bill removes that hurdle entirely. However, the bill does rely on the “follow-up care recommended by current U.S. Public Health Service guidelines.” Since those guidelines can change, there might be some administrative friction over exactly which tests or follow-up visits must be covered without cost-sharing. While this is a minor issue in the face of such broad benefits, it’s where insurers might try to draw lines.

Overall, the “PrEP and PEP are Prevention Act” is a win for public health access. It’s a clear, comprehensive mandate that puts a powerful tool against HIV into the hands of everyone who needs it, regardless of their insurance type or income, by making the price tag exactly zero.