Effective September 30, 2024 -- PrEP under Medicare Part B has no out-of-pocket costs

Effective September 30, 2024, the Centers for Medicare & Medicaid Services (CMS) began covering PrEP as a preventive service under Medicare Part B with no out-of-pocket costs. Previously, PrEP was only covered under Medicare Part D and included significant out-of-pockets costs. 

CMS’s decision to categorize PrEP and related ancillary testing and screenings as preventive services under Part B aims to improve access to PrEP and address disparities in access that exist today for Medicare enrollees who cannot afford it. 

Under the change, Medicare will cover the following services without cost-sharing: 

• PrEP (oral or injectable) for individuals at high risk of HIV acquisition 

• Administration of injectable PrEP 

• Individual counseling visits (up to 8 visits every 12 months) including: 

  • HIV risk assessment 

  • HIV risk reduction 

  • Medication adherence 

• HIV screenings (up to 8 times every 12 months)

• Single Hepatitis B virus screening 

CMS has provided a number of resources and training to pharmacies to help prepare them for this change. However, disruptions are still possible. To bill for oral HIV PrEP drugs under Part B, a pharmacy must be enrolled in Medicare as either: 1) a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier (CMS855S), or 2) a Part B Pharmacy supplier (CMS-855B). See this site for payment codes. https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf?eType=EmailBlastContent&eId=b988ea03-6b02-4626-8465-30a34f852ba1