On September 30th, the Centers for Medicare and Medicaid (CMS) announced in a new National Coverage Determination that Medicare will begin covering all forms of HIV pre-exposure prophylaxis (PrEP) approved by the Federal Drug Administration (FDA) without cost-sharing.

This determination expands access to crucial HIV prevention services by reducing financial barriers to current and future approved PrEP drugs.

PrEP was previously covered under Medicare Part D, Medicare’s pharmacy benefit. Approximately 45,000 PrEP users enrolled in Part D will be impacted by this change. Because not all pharmacists currently bill for Part B, it is important for health departments and their partners to share information about this recent change to ensure PrEP users enrolled in Medicare can continue receiving PrEP with no cost sharing.

For those qualifying, covered services include:

• FDA-approved oral or injectable PrEP medication.
• Up to 8 individual counseling sessions every 12 months.
• Up to 8 HIV screenings every 12 months.
• A Hepatitis B virus screening.

PrEP medications and related services are considered preventive care, so clients pay nothing for them if their provider accepts assignment. Clients have no out-of-pocket cost for antiretroviral drugs if received at a pharmacy enrolled in Medicare Part B.

Communicating to Clients, Prescribers, and Pharmacy Partners:

The RxEACH Coalition (Pharmacies Expanding Access to Community HIV Services) outlined key messages for PrEP clients, prescribers, and pharmacists about this recent change. Local health departments should share this messaging with their funded HIV prevention partners, clients, and other community members. The full document is available here, with key messages for providers reproduced below:

Messaging for PrEP Prescribers/Providers

• Medicare coverage for PrEP is changing from Part D to Part B. PrEP users will no longer have co-pays to access PrEP. People can access PrEP medications from any pharmacy that is enrolled in Medicare Part B. Medicare coverage for HIV treatment and post-exposure prophylaxis is not changing.
  • Encourage your PrEP users to contact their pharmacy now to verify the pharmacy will be able to provide PrEP.
  • Remind your PrEP users to bring their Medicare card (“red, white, and blue card”) with identification number when they drop off or pick up their PrEP prescription.
  • For your PrEP users with Medicare, please include a diagnosis code on all HIV treatment, PEP, and PrEP prescriptions going forward so the pharmacy can properly bill Medicare.
    • Consider adding voluntary updates to your electronic prescribing systems that will prompt for a diagnosis code on such prescriptions. When diagnosis codes are not included on prescriptions, expect increased calls from pharmacies to confirm diagnosis codes.
    • CMS provides potential diagnoses and billing codes for PrEP PrEP | CMS
    • NASTAD’s Guide may be a helpful resource: NASTAD Billing Coding Guide for HIV Prevention

CMS is advising clients whose pharmacies cannot bill Medicare for PrEP to call 1-800-MEDICARE (1-800-633-4227) for assistance finding another pharmacy where PrEP is available. TTY users can call 1-877-486-2048. Local health departments are encouraged to create a list/directory of pharmacies who can bill for Medicare to support current and potential PrEP clients.

Resources:

• Key messages for clients, providers, and providers (RxEACH)
• Fact sheet for clients (Medicare)
• Fact sheet for pharmacists (Medicare)
• FAQ for pharmacies (Medicare)
• Blog Post on HIV.gov (HHS)
• Press Release: Medicare to Cover All FDA-Approved HIV Prevention Drugs Without Cost-Sharing (The AIDS Institute)
• One-pager for clients/Medicare beneficiaries (AIDS Institute)