CMS issued a memo to Medicare Advantage and Part D plans to prepare for CMS’ anticipated transition in coverage of HIV Preexposure Prophylaxis (PrEP) from Part D to Part B.
CMS clarified that if the final policy is published as expected, MA organizations will be required to cover HIV PrEP, the additional screening tests, and counseling services as a zero-dollar cost-sharing preventive service when provided by an in-network provider.
CMS stipulated that it will not permit Part D plan sponsors to reject claims or implement prior authorization (PA) requirements on all HIV PrEP drugs. Specifically, CMS stated it will not permit Part D plan sponsors to require a PA to determine if a drug is being used for PrEP when it has indications for both HIV prevention and HIV treatment.
CMS stated that it does not expect or require that a diagnosis code be included on a prescription for any HIV prevention or HIV treatment drugs. However, if a diagnosis code is included, Part D plan sponsors may use that information to determine whether the drug should be covered under Part B, if it is being used for HIV PrEP, or Part D, if it is being used for HIV treatment or HIV post-exposure prophylaxis (PEP). CMS noted that for pharmacies to submit a Part B claim to Medicare, a diagnosis code is required on the claim.
CMS stated that Part D plan sponsors may also consider implementing point-of-sale messaging to inform pharmacies that HIV PrEP drugs are now coverable under Part B. Further, CMS expects MA organizations and Part D plan sponsors to communicate the expected change in PrEP for HIV prevention coverage to beneficiaries who may be affected. This will ensure these beneficiaries are aware that PrEP for HIV prevention is expected to no longer be covered under Part D and will instead be covered under Part B without cost sharing as an additional preventive service. CMS stated that beneficiaries should also be made aware that drugs for HIV treatment and HIV PEP will remain coverable under Part D.
Lastly, CMS encourages Part D plan sponsors to communicate this expected change to their contracted pharmacies and inform them that, if they have not already, they will need to enroll in Medicare as either: 1) a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier (using the CMS-855S enrollment application), or 2) a Part B pharmacy supplier (using the CMS-855B enrollment application) to bill Part B for PrEP for HIV prevention.
