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Potential Medicare Part B Coverage of PrEP for HIV: What You Need to Know
September 16, 2024The Centers for Medicare & Medicaid Services (CMS) released a proposal that could significantly impact the way individuals with Medicare access medications to prevent the human immunodeficiency virus (HIV). This initiative, which could eliminate cost-sharing under Medicare Part B for eligible beneficiaries, aims to expand access to pre-exposure prophylaxis (PrEP) using antiretroviral drugs (oral or injectable) approved by the US Food and Drug Administration (FDA).
Here’s an overview of the key details and potential implications of this proposed coverage change.
Expanding Access to HIV Prevention Under Medicare Part B
On July 12, 2023, CMS proposed to include PrEP medications under Medicare Part B for individuals at high risk of contracting HIV. PrEP drugs are currently covered under Medicare Part D, which typically involves out-of-pocket costs such as deductibles and copays. This new proposal aims to shift this coverage to Medicare Part B, thereby eliminating cost-sharing for beneficiaries.
Key Aspects of the Proposal:
- Coverage of Antiretroviral Drugs: The proposed coverage would apply to both oral and injectable FDA-approved PrEP drugs, making them more accessible to individuals at high risk of contracting HIV as determined by a healthcare practitioner.
- Counseling Services: CMS also proposes coverage for up to seven individual counseling sessions per year, focused on assessing HIV risk, reducing risk, and promoting medication adherence. These sessions would be provided by qualified healthcare practitioners.
- HIV and Hepatitis B Screenings: Under the proposal, beneficiaries would be eligible for up to seven HIV screenings annually and a single hepatitis B screening, covered under Part B without cost-sharing, using FDA-approved tests.
Addressing the Transition from Part D to Part B
Public feedback has raised concerns about the complexity of this transition and the risk of disrupting access to preventive medications. If finalized, the shift from Medicare Part D to Part B for PrEP coverage will require adjustments from healthcare providers, pharmacies, and Medicare beneficiaries.
For pharmacies to bill Medicare for oral or injectable HIV PrEP drugs under Part B, they must be enrolled as either a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier or a Part B Pharmacy supplier. Pharmacies not yet enrolled are encouraged to begin the enrollment process promptly in anticipation of the potential coverage change. CMS offers detailed enrollment instructions for those who are not enrolled.
Prepare Your Pharmacy for the Fight Against HIV
CMS has issued a proposed National Coverage Determination (NCD) and is reviewing public comments before making a final decision. If the proposed changes are finalized, they will take effect immediately upon issuance.
Pharmacists have the expertise and accessibility to help combat the spread of HIV. Expanding Medicare Part B to include PrEP drugs without cost-sharing puts pharmacies in a prime position to improve access to essential HIV prevention tools for individuals at high risk.
Here are three things you can do now to make sure your pharmacy is ready for the shift.
- Ensure you are enrolled as a Medicare Part B Pharmacy Supplier or DME, prosthetics, orthotics, and supplies (DMEPOS) supplier.
- Visit the Medicare Fee-For-Services Public Provider Enrollment dataset to verify your status.
- If your pharmacy is not enrolled, sign up promptly to avoid disruptions once the final rule is posted.
This initiative represents a significant step forward in HIV prevention and care. Our latest eBook, Auditing the Complexities of Medical Billing for Clinical Services and Specialty Pharmacy, gives you insights on how your pharmacy can prepare to bill for PrEP medications.