The tablets are covered; the injections aren’t

.FIRST PERSON.  COMMENTARY

When you navigate life with a chronic condition, every letter from your healthcare provider carries profound weight. It is more than administrative paperwork; it represents your daily wellness, your peace of mind and your ability to plan for your future.

Less than a month ago, I shared my journey publicly through social media and in an essay for POSITIVELY AWARE. My goal was simple: to shine a gentle light on the complexities that people often encounter when trying to access the latest medical breakthroughs, and to invite insurers—valuable partners in our healthcare—into a thoughtful conversation about how we can work together.

My new employer is the city of New Orleans, and its employee health insurance company is UnitedHealthcare. To its credit, UnitedHealthcare responded to my get-acquainted message with remarkable speed and care. In less than 30 days, a personalized, thoughtful letter arrived in my hands.

In the healthcare space, that kind of promptness is meaningful. It demonstrates that UnitedHealthcare is listening and that there can be a constructive dialogue between patients and insurers. 

As the conversation began to unfold, I realized just how many people this touches right here in New Orleans. Through conversations with community members and fellow city employees, I learned that a vast portion of our municipal workforce—from leadership at city hall to dedicated classroom educators like me—entrusts their health to UnitedHealthcare.

This makes our ongoing dialogue an incredible opportunity. When a major insurer and everyday public servants communicate transparently, everyone benefits. We have a shared interest in keeping New Orleans’ educators, civil servants and families healthy and present for the communities they serve.

In its letter, UnitedHealthcare explained my current coverage status, noting that my request for Sunlenca (lenacapavir)—a breakthrough option for individuals managing complex HIV treatment—was affected by a “plan exclusion.”

Receiving that news naturally sparked a desire to learn more. For many of us outside the insurance industry, insurance terminology can feel a bit puzzling. For example, here’s some of what United Healthcare said in its letter:

Our review confirmed that Sunlenca tablets 300 mg have been approved through prior authorization...

Our review confirmed that Sunlenca injection is not covered under your pharmacy benefit because it is an excluded medication. However, coverage may be available under your medical benefit if the medication is approved through the medical authorization process.

In addition, Sunlenca injection is a limited distribution drug (LDD), meaning the manufacturer restricts its distribution to a select network of specialty pharmacies. Based on our research, this medication may be available through CVS Specialty Pharmacy or with the buy and bill process.

This has left me with a few questions.

What does “plan exclusion” mean for my care? When my healthcare provider contacted UnitedHealthcare to complete the required prior authorization for Sunlenca, UnitedHealthcare denied it, citing a “plan exclusion.” I would like to understand in plain English what that means. What defines this exclusion under my employer-sponsored policy? Is it an absolute contractual carve-out or a formulary restriction that can be appealed through a medical necessity or formulary exception process?

Why approve the lenacapavir tablets but exclude the injections? The dosing of Sunlenca (lenacapavir) includes oral tablets during the loading (initiation) phase and subcutaneous (under the skin) injections every six months for maintenance, alongside other HIV medications. If the oral tablets were approved, what clinical or administrative basis justifies excluding the injection? Approving the starter tablets while denying the injections renders my therapy clinically incomplete.

I’m asking UnitedHealthcare to explain how my doctor and I can resolve this.

The insurance company’s approval of Sunlenca tablets is an encouraging first step. It shows that UnitedHealthcare recognizes the value of this medication. The next step is to find a collaborative way to bridge the gap so the injections can also be covered, ensuring that this breakthrough HIV drug, already approved by the U.S. Food and Drug Administration (FDA), can be accessible through my health insurer.

Every organization has to balance budgets, guidelines and administrative frameworks. Yet at the heart of healthcare, there is always a human story. When it comes to medicine, I often think of Tina Turner’s famous song “What’s Love Got to Do with It.” The answer is: quite a lot. Compassion, care and partnership are what make modern medicine so transformative.

Ensuring that people have seamless access to their complete treatment regimens isn’t just good medicine; it’s a wonderful investment in the future. It means educators like me can stay energized in their classrooms, mentors can remain active in their neighborhoods and long-term survivors can continue partnering with UnitedHealthcare for many healthy years to come.

The prompt, respectful response from UnitedHealthcare has opened a welcoming door, and I am optimistic about where this conversation can lead.

Thank you, UnitedHealthcare, for listening, for responding so quickly and for being willing to engage. When patients, educators and healthcare leaders sit down to talk with open minds and kind hearts, meaningful progress is always within reach.

Morris A. Singletary is an educator, community advocate and proud New Orleans resident.