CMS published a fact sheet for its potential coverage in Medicare Part B of Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy (oral or injectable) to Prevent Human Immunodeficiency Virus (HIV). CMS shared information to encourage pharmacies and other interested parties to prepare for a potential National Coverage Determination (NCD) for PrEP. CMS did not announce any coverage changes at the time of the fact sheet and has not yet published a final NCD. NCPA submitted comments on the proposed NCD back in August 2023. The fact sheet contains billing instructions for pharmacies and claims processing and coding instructions for pharmacies under fee-for-service Medicare. CMS’ proposed NCD, if finalized, would expand Medicare Part B coverage using the “additional preventive services” benefit under section 1861(ddd)(1) of the Social Security Act. Coverage under that benefit category would mean that beneficiaries would not be financially responsible for any cost-sharing obligations (i.e., deductibles or co-pays) for any of the above-mentioned covered services. The proposed HIV PrEP NCD is unique because HIV PrEP drugs are currently covered under Medicare Part D.
NCPA
