CMS Places All No-Cost PrEP Coverage in Medicare Part B

After taking several steps to prepare — including releasing a fact sheet, posting a technical frequently asked questions for pharmacies and launching an informational website for health care providers — CMS on Sept. 30 issued a final National Coverage Determination on Medicare coverage of HIV pre-exposure prophylaxis (PrEP). Effective immediately, coverage for PrEP will be under Medicare Part B — including oral agents previously covered under Part D — where it will be available at no cost to beneficiaries, a move that should increase adherence to treatment, industry experts say.

“At face value, moving coverage to Part B helps ensure that all Medicare recipients will have access to the HIV PrEP, as opposed to depending upon patients with stand-alone or carved-out prescription benefits to access PrEP through their prescription benefit,” observes Winston Wong, Pharm.D., president of the W-Squared Group. “I don’t believe there is any question of coverage since CMS issued an NCD, which mandates all Part D plans meet the minimum coverage requirements; however, I don’t believe carve-out prescription benefits for retirees are required to provide comparable coverage to CMS.”