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.
Want injectable PrEP without the insurance fight?
MISTR handles insurance navigation for you — or provides PrEP at $0 if you're uninsured. Free consultation, labs, medication, and delivery.
ANDR735
Using this code at signup helps us achieve our mission of getting free PrEP out to all who need it.
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.
Explore all your PrEP options
Not sure if Yeztugo is right for you? MISTR's clinicians can help you compare oral, Apretude, and Yeztugo — and find the $0 pathway that fits.
ANDR735
Using this code at signup helps us achieve our mission of getting free PrEP out to all who need it.
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.