Medicare Poised to Add Important HIV Drug to Preventive Service List

In 2023, the Centers for Medicare & Medicaid Services (CMS) opened a review to determine if Medicare should cover Preexposure Prophylaxis (PrEP)—drugs used to prevent HIV—as a preventive service for people at high risk of HIV acquisition. Medicare Rights strongly supports this coverage, and CMS appears poised to make it official in September.

The Affordable Care Act (ACA) enabled Medicare to establish preventive services that people with Medicare can access without paying a deductible or other cost sharing. These services include care like vaccines to prevent flu or pneumonia and various screenings and exams for early detection.

To determine if a service should qualify as a preventive service, CMS first gets a recommendation from the United State Preventive Services Task Force (USPSTF). If the USPSTF recommends or strongly recommends the service, CMS launches a national coverage determination process to ask for feedback and comments from stakeholders. CMS then weighs the recommendation and feedback to determine if it is appropriate to cover the service as a preventive service.

The USPSTF strongly recommended that PrEP be included as a preventive service for adolescents and adults at increased risk of HIV. In its exploration of the issue, the agency demonstrated a strong link between people adhering to their PrEP regimen and its effectiveness in preventing HIV.

Preventing new cases is vital. Despite breakthroughs in treating and managing HIV/AIDS, it remains a serious condition for over 1 million people in the United States, with nearly half age 50 and older. This population has an average of 4 core chronic diseases (including HIV/AIDS), takes 12 Part D covered drugs (including 8 maintenance drugs), and incurs high prescription drug costs. And it is a matter of equity as well. Individuals with HIV/AIDS are more likely to be members of populations affected by disparities, including Black, Latino, and LGBTQ communities.

Though PrEP is already covered by Medicare, it can accrue significant costs. Research has demonstrated a clear link between drug costs and adherence, with adherence rising as costs fall, especially for people with lower incomes.

We strongly support including PrEP as a preventive service to increase uptake of these vital medications, and CMS appears to agree. In April, the agency released a fact sheet to help prepare providers and pharmacists for a potential decision to cover PrEP as a preventive service. In June, it put out an additional frequently asked questions document for pharmacies and alerted stakeholders that it expected to make the coverage final in September. This advance notice is important because the final decision will trigger immediate coverage and providers and pharmacies must make plans to ensure there are no disruptions in people’s access to their medications.

At Medicare Rights, we believe it is crucial to limit the spread of HIV. Making PrEP a covered preventive service under Medicare Part B with zero copay is likely to increase uptake and adherence to the medication, thus improving personal and public health and well-being, and health and financial equity.