Medicare PrEP Coverage: The Basics
In September 2024, CMS finalized a National Coverage Determination that adds PrEP to Medicare Part B's preventive services. This means:
- $0 cost-sharing for FDA-approved PrEP medications (oral and injectable)
- $0 for related services including HIV testing, kidney function tests, and provider visits for PrEP management
- No deductible applies to PrEP under Part B
Before this change: PrEP was covered under Medicare Part D (prescription drug plans), which meant copays, deductibles, and the coverage gap. The Part B coverage path now offers a completely free option.
Part B vs. Part D for PrEP
| Feature | Part B (new) | Part D |
|---|---|---|
| Cost to you | $0 | Varies (up to $2,100 annual OOP cap) |
| Deductible | None for preventive | Plan-specific |
| Covers labs/visits | Yes, at $0 | Separate Part B billing |
| Prior authorization | May be required | May be required |
| Best for | Lowest possible cost | Backup if Part B claim denied |
Your provider should bill PrEP under Part B for the best coverage. If there's an issue, Part D remains a backup option with the $2,100 annual OOP cap.
Compare PrEP access options
Telehealth providers, local clinics, state programs, Medicaid, and manufacturer assistance can all be valid routes. Compare cost, lab method, medication options, location, privacy, and follow-up instead of defaulting to one provider.
Compare providers and programs →HIV in Older Adults: Why PrEP Matters After 50
People over 50 accounted for approximately 17% of new HIV diagnoses in recent CDC data. Factors that increase risk in this age group include:
- Dating after divorce or the death of a partner
- Less consistent condom use (pregnancy is no longer a concern)
- Lower likelihood of being offered HIV testing by providers
- Biological factors: thinning vaginal and rectal tissue increases susceptibility
- Later diagnosis on average, which means later treatment
PrEP is approved for adults of all ages. If you're sexually active and at any risk of HIV exposure, age is not a reason to avoid PrEP.
How to Start PrEP on Medicare
- Talk to your doctor: Ask about PrEP at your next visit. Any primary care provider can prescribe it.
- Use telehealth: Telehealth PrEP services accept Medicare and offer consultations from home.
- Request Part B billing: Make sure your provider bills PrEP services under Part B (not Part D) for $0 cost-sharing.
- Don't be shy: Providers sometimes assume older patients aren't at risk. Advocate for yourself — PrEP should be offered to anyone who asks.