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Pre-exposure prophylaxis (PrEP) for HIV prevention

Medicare Part B (Medical Insurance) covers pre-exposure prophylaxis (PrEP) medication and related services, if you’re eligible

  • Covered by Part B
  • Preventive Service

  • You pay nothing if you qualify

Description

PrEP uses antiretroviral medication to lower your risk of getting HIV (human immunodeficiency virus). 

Coverage details

Medicare Part B (Medical Insurance) covers pre-exposure prophylaxis (PrEP) medication and related services.

If you qualify, covered services include:

  • FDA-approved oral or injectable PrEP medication. If you’re getting an injectable drug, Part B also covers the fee for injecting the drug.
  • Up to 8 individual counseling sessions (including HIV risk assessment, HIV risk reduction, and medication adherence).
  • Up to 8 HIV screenings.
  • A hepatitis B virus screening.

Who's eligible

If you don’t have HIV, but your doctor or other health care provider determines you're at an increased risk for HIV.

Costs

If you get PrEP medications from a pharmacy that’s enrolled in Part B, you’ll pay nothing out of pocket for your medications. Ask your provider to include a diagnosis code on your prescription to help the pharmacy. If you’re in a Medicare Advantage Plan , you’ll usually pay nothing out of pocket for PrEP at any pharmacy in your plan’s network. Contact your plan for more specific cost information. 

If your provider accepts assignment , you’ll also pay nothing out of pocket for injectable PrEP drugs, HIV and hepatitis B virus (HBV) screenings, and counseling sessions because they’re preventive services. 

Contact your pharmacy to make sure they can bill Medicare Part B. If you don’t, you might have to pay the full cost of PrEP yourself. Most pharmacies (including national chains) can bill Part B, but some smaller pharmacies can’t. If your regular pharmacy can’t bill Part B, we can help you find a pharmacy where you can get your PrEP. Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 

How often

If you qualify, you can get

  • Up to 8 counseling sessions every 12 months.
  • Up to 8 HIV screenings every 12 months.
  • A one-time HBV screening (you may be able to get more screenings if you're at high risk for HBV or you're pregnant).

     

Ask your doctor or healthcare provider how much your test, item, or service will cost.

Your doctor may recommend services that Medicare does not cover or offers too frequently. This could end up in additional costs for you. Make sure to ask your doctor about the reasons for these recommendations and what Medicare will actually cover.

Specific amounts you could owe depend on:

  • Other insurance you may have

  • How much your doctor charges

  • If your doctor accepts assignment

  • The type of facility

  • Where you get your test, item, or service

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