The Centers for Medicare and Medicaid Services (CMS) is considering national Medicare coverage of pre-exposure prophylaxis (PrEP) to prevent HIV, notably the long-acting injectable Apretude, which is administered to people at risk for HIV every two months. As part of the analysis, CMS is seeking input from the public, particularly comments that include scientific evidence.
Comments can be submitted online on CMS.gov until February 11.
Medicare is the U.S. health insurance program for people 65 and older and for people under 65 who have certain illnesses. CMS is part of the Department of Health and Human Services.
Currently, Medicare coverage of PrEP varies by state, county and plan, Endpoints News reports. But if after completing its national coverage determination for PrEP, CMS concludes that PrEP is reasonable and necessary, then Medicare contractors in all states and jurisdictions will be required to cover PrEP.
To qualify, services must also receive a grade A (strongly recommended) or grade B (recommended) rating from the U.S. Prevention Services Task Force (USPSTF). Last month, the task force gave long-acting injectable PrEP an A grade. This was an update from a 2019 recommendation that gave oral PrEP (taken daily as tablets) a grade A.
These grades are also important because the Affordable Care Act (ACA, or Obamacare) requires that private insurers and ACA-approved health plans cover preventive services that receive an A or B grade from the prevention task force.
“Given that the USPSTF’s current Grade A recommendation, by its terms, broadly applies to all PrEP therapies (even if it was based on clinical evidence supporting daily oral tenofovir disoproxil fumarate/emtricitabine), it is appropriate to apply the USPSTF’s current Grade A recommendation for PrEP to Apretude,” Andrew Zolopa, head of ViiV North America Medical Affairs, wrote to CMS in February 2022. “Finally, provider-administered PrEP is appropriate for individuals enrolled under Medicare Part B. Data show that the Medicare program covers approximately 10% of individuals who could benefit from PrEP, including primarily younger individuals who are eligible for Medicare based on disability.”
In related news, last fall, a judge in Texas ruled that the mandate to cover PrEP for HIV prevention violates religious freedom; the plaintiff’s lawyer had argued that covering PrEP amounts to forcing Christians to support homosexual behavior.
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