H.R. 5127 — PrEP and PEP are Prevention Act

This section requires group health plans and health insurance issuers to cover HIV prevention services (i.e., FDA-approved drugs or biologicals for HIV prevention such as pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP], administrative fees, associated laboratory and diagnostic procedures, counseling, and clinical follow-up and monitoring per U.S. Public Health Service guidelines) as an additional essential health benefit under the Patient Protection and Affordable Care Act without cost-sharing or preauthorization requirements (except for a specific drug if a therapeutically equivalent alternative is covered without preauthorization), effective for plan years beginning after the date of enactment. This section also covers HIV prevention services (as defined above) as Medicare Part B outpatient services without coinsurance (i.e., 100% payment [from the prior 80%], based on the applicable fee schedule or outpatient prospective payment amount) or deductible (for the drugs and biologicals component only), effective for services furnished on or after January 1 of the first calendar year after the date of enactment. (Thus, Medicare beneficiaries previously responsible for 20% coinsurance and the Part B deductible on these services incur no out-of-pocket costs.) Additionally, this section eliminates the Part D deductible, coinsurance, and other cost-sharing for covered Part D drugs approved for HIV prevention.