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.
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.