§4317-D. Coverage of HIV prevention drugs
1.
Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A.
"CDC guidelines" means guidelines related to the nonoccupational exposure to potential HIV infection, or any subsequent guidelines, published by the federal Department of Health and Human Services, Centers for Disease Control and Prevention.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
B.
"HIV prevention drug" means a preexposure prophylaxis drug, post-exposure prophylaxis drug or other drug approved for the prevention of HIV infection by the federal Food and Drug Administration.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
C.
"Post-exposure prophylaxis drug" means a drug or drug combination that meets the clinical eligibility recommendations provided in CDC guidelines following potential exposure to HIV infection.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
D.
"Preexposure prophylaxis drug" means a drug or drug combination that meets the clinical eligibility recommendations provided in CDC guidelines to prevent HIV infection.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
2.
Coverage required.
A carrier offering a health plan in this State shall provide coverage for an HIV prevention drug that has been prescribed by a provider or that has been prescribed, dispensed and administered by a pharmacist under Title 32, section 13786‑E. Coverage under this section is subject to the following.
A.
If the federal Food and Drug Administration has approved one or more HIV prevention drugs that use the same method of administration, a carrier is not required to cover all approved drugs as long as the carrier covers at least one approved drug for each method of administration with no out-of-pocket cost. Notwithstanding this paragraph, a carrier shall provide coverage with no out-of-pocket cost for HIV prevention drugs for the prevention of the acquisition of HIV infection in accordance with a rating of A or B in the recommendations of the United States Preventive Services Task Force or equivalent rating from a successor organization and guidelines issued by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services.
[PL 2025, c. 483, §2 (AMD).]
B.
A carrier is not required to cover any preexposure prophylaxis drug or post-exposure prophylaxis drug dispensed or administered by an out-of-network pharmacy provider unless the enrollee's health plan provides an out-of-network pharmacy benefit.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
C.
A carrier may not prohibit, or permit a pharmacy benefits manager to prohibit, a pharmacy provider from prescribing, dispensing or administering any HIV prevention drugs.
[PL 2025, c. 483, §2 (AMD).]
D.
A carrier shall authorize a pharmacist to bill the carrier and receive direct payment for a service that the pharmacist provides to an enrollee pursuant to this section and shall identify the pharmacist as the provider in the billing and claims process for payment for the service. A carrier may not impose on a pharmacist, in order for the pharmacist to receive payment for a service provided pursuant to this section, a practice, education or collaboration requirement that is inconsistent with or more restrictive than a requirement of state law or agency or board rules.
[PL 2025, c. 483, §2 (NEW).]
[PL 2025, c. 483, §2 (AMD).]
3.
Limits on prior authorization and step therapy requirements.
Notwithstanding any requirements in section 4304 or 4320‑N to the contrary, a carrier may not subject any HIV prevention drug to any prior authorization or step therapy requirement except as provided in this subsection. If the federal Food and Drug Administration has approved one or more methods of administering HIV prevention drugs, a carrier is not required to cover all of the approved drugs without prior authorization or step therapy requirements as long as the carrier covers at least one approved drug for each method of administration without prior authorization or step therapy requirements. Notwithstanding this subsection, a carrier shall provide coverage without prior authorization or step therapy requirements for HIV prevention drugs for the prevention of the acquisition of HIV infection in accordance with a rating of A or B in the recommendations of the United States Preventive Services Task Force or equivalent rating from a successor organization and guidelines issued by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services. If prior authorization or step therapy requirements are met for a particular enrollee with regard to a particular HIV prevention drug, the carrier is required to cover that drug with no out-of-pocket cost to the enrollee.
[PL 2025, c. 483, §3 (AMD).]
4.
Coverage for laboratory testing related to HIV prevention drugs.
A carrier offering a health plan in this State shall provide coverage with no out-of-pocket cost for laboratory testing recommended by a provider related to the ongoing monitoring of an enrollee who is taking an HIV prevention drug covered by this section.
[PL 2021, c. 265, §4 (NEW); PL 2021, c. 265, §8 (AFF).]
SECTION HISTORY
PL 2021, c. 265, §4 (NEW). PL 2021, c. 265, §8 (AFF). PL 2025, c. 483, §§2, 3 (AMD).