PrEP labs and Medicare

[edgewater57]

I just turned 65 and started Medicare, and heard from someone that Medicare doesn't cover the quarterly STI labs that are part of the protocol for being on PrEP. Can any others on Medicare and PrEP tell me what you have discovered and any strategies for making this aspect of PrEP affordable?

 

[winesthel945]

There's a lot of documentation online about Medicare only covering STI screening once per year. But many of those resources don't appear to have been updated since the Affordable Care Act updates in 2021. There's an FAQ document from the HHS and DOL at: https://www.dol.gov/sites/dolgov/fi...tivities/resource-center/faqs/aca-part-47.pdf

According to the FAQ, PrEP must be covered for free by all insurance programs and since PrEP requires quarterly lab work, that must be covered for free as well. The FAQ implies that Medicare or Medicaid should cover it, but it doesn't explicitly state it. All the other guidance documentation on the CMS.gov site comes from circa 2010 and obviously won't reflect recent changes.

You may need to look into testing from your local public health authority or community clinic that can access Medicaid funds to cover it. An article notes that a lot of places still haven't gotten the message that PrEP and its associated tests should be covered. PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans

Also ran across this: Medicare Coverage for Truvada

Good luck!

 

[edgewater57]

There's a lot of documentation online about Medicare only covering STI screening once per year. But many of those resources don't appear to have been updated since the Affordable Care Act updates in 2021. There's an FAQ document from the HHS and DOL at: https://www.dol.gov/sites/dolgov/fi...tivities/resource-center/faqs/aca-part-47.pdf

According to the FAQ, PrEP must be covered for free by all insurance programs and since PrEP requires quarterly lab work, that must be covered for free as well. The FAQ implies that Medicare or Medicaid should cover it, but it doesn't explicitly state it. All the other guidance documentation on the CMS.gov site comes from circa 2010 and obviously won't reflect recent changes.

You may need to look into testing from your local public health authority or community clinic that can access Medicaid funds to cover it. An article notes that a lot of places still haven't gotten the message that PrEP and its associated tests should be covered. PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans

Also ran across this: Medicare Coverage for Truvada

Good luck!

Thank you for taking the time to contribute to the discussion. From what I have discovered so far, Medicare is not a "health plan" to which the ACA rules apply. Medicare seems to have its own, much smaller, list of covered preventive care services. I have already clearly discovered that Medicare Part D prescription drug insurance does NOT cover Truvada/Descovy with no copay (as is now required for ACA-governed plans, which was great before I turned 65). There are CoPay patient-assistance foundations that I have found to help with the drug co-pays themselves, but I'm curious to hear from other Medicare beneficiaries on PrEP what solutions they have found.

 

[LPSG Simon]

There should be a free clinic in your city that does these tests whose documentation you can use to get your prescription renewed, no?