The Coverage Landscape Right Now
Yeztugo is a game-changer for HIV prevention — two injections per year, up to ~100% efficacy. But its $28,218 annual list price created a standoff between Gilead and insurance companies. Here's how coverage has evolved:
What's covered
Under the Affordable Care Act, PrEP has a USPSTF Grade A recommendation, which means insurance plans must cover FDA-approved PrEP without cost-sharing. This includes Yeztugo. However, insurers can still impose prior authorization, step therapy (requiring you to try oral PrEP first), and preferred-drug requirements.
The PBM situation
The major pharmacy benefit managers (PBMs) control formulary decisions for most commercial insurance:
- CVS Caremark: Initially declined to cover Yeztugo in 2025. Coverage expanding in 2026 but may require prior authorization and step therapy.
- Optum/OptumRx: Excluded from premium formulary; tier 3 on select formulary. Cited higher net cost versus alternatives.
- Express Scripts: Coverage varies by plan. Generally requires prior authorization.
Medicare coverage
Medicare Part B now covers PrEP services including injectable PrEP at $0 cost-sharing as of September 2024. Part D plans also cover Yeztugo with the $2,100 annual out-of-pocket cap for 2026. CMS approved new HCPCS J-codes for lenacapavir effective October 1, 2025.
Medicaid
State Medicaid programs generally must cover FDA-approved PrEP. Four states (FL, KY, NY, WY) currently require prior authorization for PrEP drugs. Check your state page for details.
How to Get Yeztugo Covered by Your Insurance
Step 1: Ask your provider to submit a prior authorization
Most insurers require prior authorization for Yeztugo. Your prescribing provider's office should submit this. Common approval criteria include: documented HIV risk factors, inability to adhere to oral PrEP, or preference for long-acting prevention.
Step 2: Use Gilead Advancing Access for support
Gilead's Advancing Access program offers dedicated specialists who will:
- Research and verify your specific insurance benefits
- Navigate prior authorization requirements
- Handle appeals if you're initially denied
- Enroll you in the copay program or Medication Assistance Program
Contact them at 1-800-226-2056 or visit prep.advancingaccess.com.
Step 3: Appeal any denial
If your insurer denies Yeztugo, appeal. Under the ACA, they're required to cover PrEP without cost-sharing. Your Advancing Access specialist can help you build the case. Common successful appeal arguments: documented non-adherence to oral PrEP, medical contraindication to oral options, or patient preference supported by clinical evidence.
How to Pay $0 for Yeztugo
| Your situation | Program | Your cost |
|---|---|---|
| Commercially insured | Gilead Copay Savings Program | $0 (up to $8,000/year covered) |
| Medicare Part B | Medicare PrEP coverage | $0 cost-sharing |
| Medicare Part D | Part D + copay assistance | $0–$2,100/year (OOP cap) |
| Medicaid | State Medicaid program | $0 (most states) |
| Uninsured | Gilead MAP (Medication Assistance Program) | $0 if eligible |
Injection administration costs: The Gilead copay program covers up to $100 per injection visit for administration fees (not available in MA, MN, or RI). Your provider's office handles the injection — it's subcutaneous, not intramuscular.
Yeztugo vs. Apretude: Quick Comparison
| Feature | Yeztugo (lenacapavir) | Apretude (cabotegravir) |
|---|---|---|
| Frequency | Every 6 months | Every 2 months |
| List price/year | ~$28,218 | ~$22,000 |
| Injection type | Subcutaneous | Intramuscular (gluteal) |
| Oral lead-in | Tablets on days 1–2 | 1 month of oral cabotegravir |
| Manufacturer | Gilead Sciences | ViiV Healthcare |
| Copay program cap | $8,000/year | ~$7,850/year |
For a full comparison, see our Yeztugo vs. Apretude guide.