CMS issues PrEP NCD
On September 30, CMS issued a final national coverage determination (NCD) for pre-exposure prophylaxis (PrEP) using antiretroviral drugs to prevent HIV in high-risk individuals. HIV PrEP drugs were previously covered under Part D, but now that CMS has transitioned coverage to Part B, beneficiaries will have no cost-sharing obligations.
CMS will also cover the following services without cost-sharing:
- Administration of injectable PrEP
- Supplying or dispensing of the drug (oral and injectable)
- Up to eight individual counseling visits every 12 months (including risk assessment, risk reduction, and medication adherence)
- Up to eight HIV screening tests every 12 months
- A single screening for hepatitis B virus
Following the final NCD publication, CMS updated a technical FAQ for pharmacies on HIV PrEP coverage. Pharmacies can bill for the drug if they are enrolled as a durable medical equipment, prosthetics, orthotics, and supplies or Part B pharmacy supplier. The FAQ details enrollment, relevant codes, and claim considerations for pharmacies.
Organizations should include at least one valid ICD-10-CM diagnosis code on prescriptions they send to pharmacies to help them prepare their Part B claims, according to CMS. Examples of appropriate diagnosis codes include those for HIV PrEP encounter, HIV screening encounter, and increased risk factors.
CMS plans to further address payment policies for HIV PrEP in the 2025 Medicare Physician Fee Schedule and Outpatient Prospective Payment System final rules, which are scheduled to be published later this fall. Revenue integrity professionals can find additional coding and billing guidance on CMS’ HIV PrEP web page and updated Part B fact sheet.