Pharmacy Benefit vs. Medical Benefit: Deciphering Coverage Pathways for HIV Medications

The advent of longer-acting injectable antiretroviral therapy (ART) for the prevention and treatment of HIV has created more options for people at risk of and living with HIV. There are several Food and Drug Administration (FDA) approved longer-acting injectable ARTs on the market, and more options in the research pipeline. Unlike an oral medication (typically a pill taken daily), longer-acting injectable ARTs are currently available as an intramuscular or subcutaneous injection administered by a provider every one, two, or six months depending on the product. Because of the different ways they are administered, longer-acting injectable medications are sometimes covered differently than oral medications by public and private payers. The different coverage pathways for these products can impact patient access and affordability as well as the ability of providers to sustainably procure and administer these products. This issue brief will describe the ways that longer-acting injectable ARTs are covered by public and private payers and the impact these coverage pathways have on access, affordability, and HIV clinic sustainability.

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