Medicare Beneficiaries Can Now Access PrEP Without Cost-Sharing

Will Help Speed HIV Prevention in Population Increasingly Impacted by HIV

Washington DC… Today CMS issued a National Coverage Determination (NCD) that requires Medicare to cover all forms of PrEP to prevent HIV without cost-sharing. Thanks to the Affordable Care Act, preventive services recommended by the United States Preventive Services Task Force can be covered by Medicare Part B without a copay once CMS has conducted an NCD. Now that these lengthy processes have concluded, beneficiaries can immediately access PrEP and its associated services at no cost.

“We commend the Biden-Harris administration for increasing PrEP uptake using all the tools at its disposal. Patient cost-sharing has been a significant barrier for Medicare beneficiaries. With this new NCD, people on Medicare can join those with private insurance who can access PrEP without cost-sharing. Now we have to make sure these policies are properly implemented and enforced,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute.

While HIV+Hep has been the leading community organization calling for the NCD ever since the USPSTF updated its PrEP recommendation to include long-acting PrEP, at the same time we have continuously voiced our concerns with moving the over 45,000 Medicare daily oral PrEP users currently receiving coverage from the Part D Program. The NCD moves coverage of all PrEP medications, both oral and long-acting, to Part B, which is typically used for provider-administered drugs. Pharmacies are not all prepared to bill for Part B and there are new policies and complex and time-consuming requirements for pharmacies and clinicians to consider when billing Part B services. 

“Over the last year, CMS has worked with us and others to address these complications, and we thank them for delaying the start of this NCD, continued Schmid. “However, it is important that no one currently receiving oral daily PrEP is forced to delay filling their prescription, particularly since there is no transition period. We urge CMS to pay close attention to any short-term disruptions and to continue to consult closely with patients, providers, pharmacies, and plans as they implement the NCD.”

The NCD also makes clear, as we recommended in our comments, that it covers all future long-acting forms of PrEP. This is particularly important as there are promising new formulations of long-acting PrEP—oral and injectable—in the drug development pipeline.

“Today’s announcement moves us closer to the day when all who have a reason to be on PrEP are able to access the medication and associated services they need without financial barriers, which will hasten the end of the HIV epidemic,” concluded Schmid.

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The HIV+Hepatitis Policy Institute is a national, non-profit organization whose mission is to promote quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.