Today, ASHP CEO Paul W. Abramowitz met with White House senior administration officials to discuss the National Coverage Determination (NCD) for pre-exposure prophylaxis (PrEP) for HIV prevention that would shift coverage of these services from Medicare Part D to Part B.
During the meeting, administration officials provided an overview of the scope of the NCD and the patient benefit of covering PrEP medication services under Part B, which would allow patients to receive these preventive services without cost-sharing.
Abramowitz expressed ASHP’s support for removing financial barriers to PrEP, but detailed some unintended adverse consequences of the NCD, along with proposed solutions to prevent patient harm.
Specifically, shifting PrEP medication coverage to Part B will disrupt patient access in the 27 states where pharmacists are authorized to provide PrEP, either via independent initiation or through a collaborative practice agreement. Under the new NCD, valid prescriptions written by these pharmacists might not be reimbursed by Medicare Part B because pharmacists cannot enroll in the Provider Enrollment, Chain, and Ownership System (PECOS) as prescribers. Additionally, the new NCD may unintentionally delay care because some medications used for PrEP under Part B would continue to be covered under Part D for other indications, including post-exposure prophylaxis. For drugs covered under both Medicare Part B and Part D, plans require a B versus D coverage determination, which is administratively complex and likely to cause significant delays in care for many patients.
To address these concerns, ASHP suggested several potential solutions, including:
- Maintaining coverage of PrEP services in Part D
- Creating a Part B pharmacist payment pathway for PrEP assessment and medications
- Recognizing prescriptions from any state-authorized provider for Part B Durable Medical Equipment, Prosthetics, Orthotics, and Supplies and allow pharmacists to register through PECOS
- Carving out medications included under the NCD from all prior authorization requirements to protect patient care from unnecessary disruptions
ASHP will follow up directly with administration officials to provide additional details regarding our concerns related to the NCD and opportunities to expand patient access to PrEP. We will closely monitor progress on the PrEP NDC and update members on new developments.
