Traditional MedicareCoverageMedium impact
25-042 Find Out What Changed: New Coverage Requirements for PrEP
Health Net·CA · Infectious Disease, Internal Medicine, Family Medicine·Pharmacy
Effective date
Sep 30, 2024
We identified it
Jun 20, 2026
Summary
Effective September 30, 2024, Medicare coverage for PrEP drugs shifted from Part D to Part B with $0 cost sharing. PPGs with risk for injectable drugs must update their claims payment systems to reflect this coverage change for FDA-approved PrEP medications including Apretude, Descovy, and Truvada when prescribed for HIV prevention.
Action Required
Immediately: PPGs with risk for injectable drugs in their Medicare DOFR must update claims payment systems to process PrEP drugs under Medicare Part B instead of Part D. Ensure billing system reflects $0 cost sharing for FDA-approved PrEP drugs (Apretude, Descovy, Truvada) when prescribed for HIV prevention. Verify diagnosis codes are included on all PrEP prescriptions to distinguish from HIV treatment coverage.