Notice of Changes by Medicare That May Affect Drug Coverage
Date: 10/31/24
As of September 30, 2024, there is a change in the way Medicare covers antiretroviral therapy that is approved by the U.S. Food and Drug Administration (FDA) to prevent human immunodeficiency virus (HIV) infection in individuals at high risk of acquiring HIV. Use of these medications to prevent HIV infection is known as pre-exposure prophylaxis (PrEP).
Based on new Medicare coverage rules, medications prescribed for PrEP will be covered under Medicare Part B without cost sharing (i.e., deductibles or copays) as an additional preventive service. PrEP medications will no longer be covered under the Medicare Part D benefit. Medications for HIV treatment and HIV post-exposure prophylaxis (PEP) will remain coverable under Medicare Part D.
The table below lists the medications that are FDA-approved to be used as PrEP for HIV prevention. Please note that some of these medications are also FDA-approved to be used for HIV treatment.
Brand Drug Name | Generic Drug Name | FDA-Approved Use |
Apretude® | cabotegravir | PrEP for HIV prevention |
Descovy® | emtricitabine and tenofovir alafenamide | PrEP for HIV prevention HIV treatment |
Truvada® | emtricitabine and tenofovir disoproxil fumarate | PrEP for HIV prevention HIV treatment |
emtricitabine and tenofovir disoproxil fumarate | emtricitabine and tenofovir disoproxil fumarate | PrEP for HIV prevention HIV treatment |
As of September 30, 2024, Apretude will no longer be covered under Medicare Part D since it is only FDA-approved for PrEP for HIV prevention.
In addition, Descovy, Truvada, and generics for Truvada will be covered only under Medicare Part B when used for PrEP for HIV prevention but will remain covered under Medicare Part D when used for HIV treatment.
A diagnosis code should be included on all prescriptions if you are prescribing one of these medications for PrEP for HIV prevention.
Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the information above, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who is your representative, please email us at WI_Provider_Relations@mhswi.com.