Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

Medi-Cal Logo
Click to Sign Up for MCSS emails

Erroneous Treatment Delays and Denials for HIV PrEP and PEP

December 11, 2017

The Department of Health Care Services (DHCS) has recently been made aware of incidents of erroneous treatment delays and denials for HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) used to prevent seroconversion to HIV. These incidents have negatively impacted beneficiary health. In most of the identified cases the cause for delay/denial of a service was a basic lack of information/understanding related to the scope of benefits and/or claims processes involved with billing for the service.

For Medi-Cal beneficiaries enrolled in a Managed Care Plan (MCP), PrEP and PEP medications are noncapitated. These medications are billed and reimbursed as Medi-Cal fee-for-service claims for both MCP and fee-for-service beneficiaries. When used as a preventative regimen for people at risk of acquiring HIV (PrEP) or for post-exposure treatment, these medications do not require a Treatment Authorization Request (TAR) as DHCS understands the consequence of delaying or denying access to these life-altering medications.

Many of the delays and denials involve pharmacies in the MCP networks not dispensing PrEP and PEP and pharmacy staff incorrectly informing beneficiaries that PrEP and PEP are not benefits of Medi-Cal. There have also been reports of medical providers misinforming patients that PrEP treatment is not a benefit, therefore refusing to issue a prescription for the medications, and instructing patients to use condoms along with traditional safe sex practices.

DHCS encourages timely access, as delays in access to these medications may have deleterious health effects for beneficiaries, including seroconversion from HIV negative to HIV positive. It is the responsibility of pharmacy providers, medical providers and ancillary staff to be fully informed about the scope of benefits and the proper submission of claims for noncapitated drugs. DHCS requests that all Medi-Cal providers, both MCP and fee-for-service, review the scope of benefits associated with drugs used to prevent the transmission of HIV. DHCS encourages providers to take appropriate actions to ensure that all ancillary staff are equally well informed regarding the scope of benefits and the processes and procedures for providing and billing for the medications when it is medically necessary.