HIV/AIDS > > HIV/AIDS– Medicare’s choice to cover all PrEP drugs under Part B has unforeseen advantage for enrollees
by Joyce Frieden, Washington Editor, MedPage Today October 2, 2024
Carl Schmid and his coworkers got more than they anticipated– in a great way– when they asked for that Medicare cover long-acting physician-administered HIV pre-exposure prophylaxis (PrEP) drugs under its Part B program.
Oral PrEP drugs had actually been spent for under Medicare’s Part D drug program, however Part D does not usually cover physician-administered drugs. And although some Part D strategies had actually been spending for the long-acting PrEP anyhow, others had actually not been, discussed Schmid, who is executive director of the HIV+H epatitis Policy Institute in Washington, D.C. The most current information, which are a number of years of ages, recommended that “a number of hundred” Medicare recipients were on the long-acting drugs, however “that has actually most likely increased to a couple thousand” considering that, he included.
2 years earlier, Schmid’s group, as well as other companies and impacted drugmakers, asked Medicare for a National Coverage Analysis that would permit long-acting PrEP to be covered under Medicare Part B, which covers physician-administered drugs. “We required a method to cover the injectable HIV avoidance drugs, which’s what required the request for the protection decision,” Schmid stated in a phone interview. “What we didn’t understand was they would move the oral PrEP to Part B at the exact same time.”
CMS authorities informed Schmid that the firm can’t break up protection of drugs to avoid or deal with a particular illness in between various parts of the Medicare program; the drugs all need to be covered under the very same program. Which modification, which worked under Medicare’s National Coverage Determination provided on Monday, has an unforeseen advantage for the roughly 45,000 Medicare enrollees taking the everyday oral medications: they will go from having a copay under Part D to no copay under Part B.
Schmid stated although he’s delighted about that surprise benefit, the shift to Part B is not without problems. “The problem is that drug stores are not registered to expense for drugs in Part B,” he stated. “They need to use– it’s a 50-page file to use– get a website evaluation, and after that they need to have a medical diagnosis code to get compensated.”
In addition, “there’s [a] various repayment” system under Part B– “you have PBMs [pharmacy benefit managers] who are associated with Part D, with refunds and all that,” Schmid stated. “That does not exist with Part B; the PBMs run out it. It’s a repayment design, so the pharmacists need to purchase the drug initially, and they’re fretted they might not get appropriate compensation from Medicare. And considering that it’s going to remain in the Part B schedule, they do not even understand when their repayment is going to be.”
Fortunately is that up until now, “payers and strategies and drug stores are being versatile,” he stated.