Question: Does the Centers for Medicare & Medicaid Services (CMS) cover medication for prophylactic transmission prevention of human immunodeficiency virus (HIV)?
Washington, D.C. Subscriber
Answer: On Sept. 30, 2024, CMS released the Pre-Exposure Prophylaxis (PrEP) to prevent HIV national coverage determination (NCD). This NCD established coverage of certain drugs under the Part B additional preventive services benefit.
HIV or human immunodeficiency virus is a virus that attacks the body’s immune system and causes acquired immunodeficiency syndrome (AIDS). HIV enters a body and destroys a type of white blood cell that is vital to fighting off infection.
Before 2025, some drugs for HIV were paid through Medicare Part D, and patients paid a deductible and coinsurance or copayments.
The U.S. Food and Drug Administration (FDA) approved three PrEP medications, and CMS pays for them under this benefit, according to a Drugs Covered as Additional Preventive Services (DCAPS) fee schedule.
Medicare Part B pays for additional preventive services not described in the preventive services definition (See §410.2).
Payment is possible under the additional preventive services benefit for medical conditions or risk factors for individuals if an NCD process shows that these services meet certain requirements.
Requirements are defined as:
1. Reasonable and necessary for the prevention or early detection of illness or disability,
2. Recommended with a grade of A or B by the U.S. Preventive Services Task Force, and
3. Appropriate for individuals entitled to Part A benefits or enrolled under Part B.
Note: A- and B-grade recommendations are highly recommended services, as they have a high or moderate net benefit for patients.
Noteworthy: CMS has never covered or paid for any drugs or biologicals under the additional preventive services benefit category.
Providers should include at least one valid ICD-10-CM diagnosis code when billing for PrEP, including codes for:
If an individual currently has HIV and uses antiretroviral drug treatments covered under Part D, Part D will continue to cover these drugs, even though they may be the same drugs that are used for HIV PrEP.
Review the fact sheet here, and find eligibility, billing, and coding details here and at the MLN website.
This information was accurate at the time of publication.
Patricia Zubritzky, BS, CRCE-I, Contributing Writer, Pittsburgh
