NCD PrEP for HIV Prevention 2025
Effective Date:9/30/24
Impacted Plans:MetroPlus UltraCare, MetroPlus Medicare Advantage and MetroPlus Platinum.
Dear MetroPlusHealth Provider:
As of September 30, 2024, MetroPlus Health Plan covers the following HIV and related preventative services without cost-sharing (for example, deductibles or copayments under Part B):
• FDA-approved Pre-exposure Prophylaxis (PrEP) using antiretroviral drugs to prevent HIV in individuals at increased risk
o Please note, when prescribing HIV PrEP medication, providers must include the appropriate ICD-10 code indicating the drug was prescribed for PrEP to ensure claims are appropriately adjudicated under Part B. For example: HIV pre-exposure prophylaxis with ICD-10 code Z29.81 on the prescription will help ensure the patient receives the right benefit coverage.
• Administration of injectable PrEP using antiretroviral drugs to prevent HIV
• Supplying or dispensing the drug regardless of the route of administration (oral and injectable)
• Individual counseling (up to 8 visits every 12 months), including:
o HIV risk assessment (initial or continued assessment of risk)
o HIV risk reduction
o Medication adherence
• HIV screenings (up to 8 times every 12 months using FDA-approved laboratory tests and point-of-care tests)
• Hepatitis B virus screening (1 time only)
Please review the documents linked below, which includes the finalized NCD, billing guidance and the updated Fact Sheet. Medicare Part B Coverage of Pre-exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Prevention: https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf
If you have any questions regarding this memo, please contact MetroPlusHealth at: ProviderRelationsOps@metroplus.org.
Thank you.
MetroPlusHealth
PRV 25.002