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Insurance coverage inconsistent for HIV prevention drug Truvada in Alberta

FILE - A doctor holds Truvada pills at her office in San Francisco.
 (AP Photo/Jeff Chiu).
FILE - A doctor holds Truvada pills at her office in San Francisco. (AP Photo/Jeff Chiu). AP Photo / Jeff Chiu

Phil Ollenberg’s doctor was convinced he was a prime candidate to be prescribed Truvada as part of a drug regimen to prevent HIV.

“I’m in an open relationship where I do have sex with multiple partners,” said Ollenberg. “Condoms are fantastic, they are effective against every sexually transmitted infection (STI), but they’re not 100 per cent effective.  And especially when it comes to anal sex, they’re much less than 100 per cent effective.”

Those who are in a relationship with a partner who is HIV positive, engage in sex with those of unknown HIV status, have multiple sex partners, and have been diagnosed with other sexually transmitted infections in the past six months are all considered at a high risk for HIV transmission and could be candidates to take Truvada.

READ MORE: Doctors celebrate as Health Canada approves Truvada as HIV-prevention therapy

Studies show that when used in conjunction with safer sex practices, Truvada as a pre-exposure prophylaxis (PrEP) can be up to 99 per cent effective in preventing the transmission of HIV.

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“I was lucky enough to find a fantastic general practitioner who was very informed on PrEP,” said Ollenberg.  “(He) had previously been to a conference on these topics and before I could open my mouth and bring it up, he was already bringing this up to me.”

Truvada is not an inexpensive drug.  A single pill costs roughly $30.  At one pill a day, a monthly prescription costs in the neighbourhood of $900.

“That’s not a disposable amount that most people have to commit toward casual sex or even regular sex with their partner who might be HIV positive,” Ollenberg said.

READ MORE: HIV prevention drug Truvada difficult for some to access in Alberta

Truvada is currently not covered by Alberta’s public drug benefit plan, and coverage – as Ollenberg found out – is not always available through group benefits.

“Under both my own and my partner’s plan, it was not covered under private group insurance.”

News Talk 770 contacted six major group benefit insurers to find out their policies on providing coverage for Truvada as PrEP.

Alberta Blue Cross said Truvada is available for coverage, “but, eligibility depends on the particular plan and may require special authorization.”

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Sun Life Financial said Truvada, “is normally covered under Sun Life’s group benefit plans. Claims for out of pocket expenses will vary based on (the) level of coverage available under a particular plan.”

Similarly, the Great-West Life Company (which includes the brands London Life and Canada Life) said Truvada is covered under most group benefit plans, but each plan sponsor has a variety of options which define the coverage offered.

“As such, plan designs may differ in whether they cover the drug.”

LISTEN: John Himpe reports on inconsistent insurance coverage for Truvada in Alberta

Manulife said that it does not provide coverage for Truvada in Alberta because they contend it is “available under a provincial program.”

While it is true that the Alberta Specialized High-Cost Drug Plan provides coverage of Truvada for those diagnosed as HIV positive and are using the drug for post-exposure treatment, the province does not cover the cost for those using it as a preventative regimen under the provincial drug benefits plan.

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In its initial response to News Talk 770, Manulife wrote :

“If one of our beneficiaries does not qualify for publicly funded Truvada, Manulife requires both the diagnosis and a list of any reasons why the patient is not eligible under the provincial program. Once submitted, eligibility is determined as per the terms of the contract.”

When asked for clarification on its policy, Manulife replied to News Talk 770 :

“The claims adjudication rules at Manulife, to which Truvada is subject, will either approve or decline the claim based on the Drug Identification Number (DIN), not based on the condition the drug is being used to treat.”

Green Shield and Group Medical Services did not reply to our e-mails seeking comment for this story.

READ MORE: Pharmacies in Edmonton, Fort McMurray to offer free HIV tests

“There’s really a lack of consistency and a lack of clarity on the private insurance coverage for PrEP,” said Andrea Carter, with Calgary-based HIV Community Link. “I know some people here in Calgary who might be with ‘Company A’ and have 100 per cent coverage, other people are also with ‘Company A’ and have 50 per cent coverage, and another person with ‘Company A’ has zero coverage.”

Ollenberg said ultimately he wasn’t surprised to learn his insurer had denied his claim for Truvada.

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“Insurance companies, I recognize at the end of the day, virtually all of them are large, multinational, publicly traded companies. They have a responsibility to their shareholders,” he said. “While it didn’t work in my favour, I do understand they have to manage costs.”

Generic versions of Truvada could be on the horizon.  On July 26, Health Canada approved applications by three manufacturers to produce generic versions of emtricitabine/tenofovir disoproxil fumarate.  In an ad on its website, Teva Pharmaceuticals said its product is “now available.”

Carter said initial generic versions of a product like Truvada do come at a reduced cost, but may save consumers and drug plans only about 30 per cent off the price of the brand name version.

Ollenberg feels the emergence of generics on the market should drastically change the conversation as to whether the province and group benefit insurers provide coverage for the treatment.

“It should be raining blue pills at that point.”