HR7853-119

What This Bill Does

The PrEP Access and Coverage Act requires group and individual health plans to cover FDA-approved prescription drugs used to prevent HIV, drug-administration fees, related laboratory and diagnostic services, and clinical follow-up and monitoring recommended by current U.S. Public Health Service guidelines without cost-sharing. The requirement also reaches grandfathered plans, Federal employee plans, Medicaid, the Children's Health Insurance Program, Medicare Part B, Medicare Part D, TRICARE, and veterans' health care. Most public-program changes take effect January 1, 2027, with a limited delay where State legislation is required.

Plans and issuers generally may not require preauthorization for these services. A particular PrEP drug may be subject to preauthorization only when a therapeutically equivalent drug is covered without preauthorization. Parallel prohibitions are added to the Public Health Service Act, ERISA, and the Internal Revenue Code. Medicare Part D deductibles and cost-sharing are eliminated for covered HIV-prevention drugs, and parallel payment protections apply to Medicare Part B, Medicaid, CHIP, Federal employee, military, and veterans' programs.

Life, disability, and long-term-care insurers may not deny coverage, require a person to stop taking PrEP, increase premiums, cancel coverage, or otherwise discriminate based solely on PrEP use without another actuarial risk. Insurers may still consider an HIV diagnosis, other medical conditions, and otherwise lawful tests. State insurance regulators may enforce the rule under State law.

HHS, CDC, HRSA, and the Office of Infectious Disease and HIV/AIDS Policy must operate public and provider education campaigns about PrEP and post-exposure prophylaxis. Campaigns must focus on underuse and disparities, collaborate with communities overrepresented in the domestic HIV epidemic, address cultural competence and stigma, and evaluate results. The bill authorizes, but does not directly appropriate, sums necessary for fiscal years 2026 through 2030.

HHS must amend Federal health-privacy regulations so a person can use covered PrEP benefits under a family plan without another enrollee, including the primary subscriber or policyholder, being informed. Within one year, HHS must also establish grants for States, territories, Indian Tribes, and eligible nonprofits serving uninsured or underinsured people. Grant funds may pay for PrEP and PEP drugs, administration, testing, monitoring, outreach, adherence counseling, and patient navigators. Public grant-impact reports are required for the first five years, and sums necessary are authorized for fiscal years 2026 through 2030.

The Act applies notwithstanding other law, expressly including the Religious Freedom Restoration Act. Any aggrieved person may sue individually or as a class, and a prevailing plaintiff must receive costs and reasonable attorney fees. HHS, Labor, and Treasury must issue guidance, assist regulators and consumers, monitor compliance, and enforce the coverage rules. Plans and issuers must report claims and cost-sharing data annually for ten years, and the three departments must submit public compliance reports every two years during that period.

Who Benefits and How

People seeking PrEP gain broad zero-cost coverage, reduced preauthorization, confidential family-plan use, and a private enforcement right. Uninsured and underinsured people may receive drugs and services through grants. Communities disproportionately affected by HIV receive targeted outreach. PrEP prescribers gain education and grant-supported navigation resources. Drug manufacturers, laboratories, clinics, and pharmacies may gain demand from expanded coverage.

Who Bears the Burden and How

Health plans and issuers must cover drugs and related services without cost-sharing, constrain preauthorization, protect confidentiality, submit annual data, and face public or private enforcement. Life, disability, and long-term-care underwriters lose the ability to use PrEP alone as an adverse factor. HHS, Labor, Treasury, CDC, HRSA, Defense, Veterans Affairs, Medicare, Medicaid, CHIP, and State regulators receive implementation duties. Federal and State taxpayers finance public coverage, grants, campaigns, and administration.

Key Provisions

• Requires zero-cost coverage of FDA-approved PrEP and related care.
• Limits preauthorization to drugs with a no-preauthorization equivalent.
• Extends coverage across private and major Federal health programs.
• Eliminates specified Medicare deductibles and cost-sharing.
• Bars specified insurance discrimination based solely on PrEP use.
• Establishes public and provider education campaigns.
• Protects confidential PrEP use under family plans.
• Creates grants for uninsured and underinsured access.
• Applies notwithstanding the Religious Freedom Restoration Act.
• Authorizes individual and class civil actions.
• Requires annual plan compliance data for ten years.
• Requires recurring public Federal enforcement reports.