Medicare Coverage for HIV & PrEP: 2025 Guide

More than 1.2 million Americans are living with HIV, and that population is aging — by 2030, more than half of people with HIV in the U.S. will be over age 50, making Medicare an increasingly important insurer for HIV care. Additionally, since September 2024, Medicare covers PrEP (pre-exposure prophylaxis) medication and related services at no cost under a landmark preventive coverage ruling. Here's what Medicare covers for both HIV treatment and prevention.

HIV & PrEP Coverage Quick Reference

PrEP Coverage: The September 2024 Change

Pre-exposure prophylaxis (PrEP) reduces the risk of HIV transmission by more than 99% when taken consistently. Despite this proven effectiveness, PrEP uptake has been limited in part by cost barriers.

Following a federal court ruling (Braidwood Management v. Becerra) that initially threatened preventive care coverage, CMS took action to preserve and extend PrEP preventive coverage for Medicare beneficiaries. As of September 2024, Medicare covers:

• PrEP medications at $0 cost sharing — including Truvada (emtricitabine/tenofovir disoproxil fumarate), Descovy (emtricitabine/tenofovir alafenamide), and generic emtricitabine/TDF
• HIV testing required before and during PrEP use — $0
• Kidney function tests (required monitoring during PrEP) — $0
• STI screening associated with PrEP monitoring — $0

If you are at substantial risk for HIV — including men who have sex with men with a recent STI or multiple partners, people who inject drugs, or partners of people with HIV — ask your doctor about PrEP.

Antiretroviral Therapy (ART): The $2,000 OOP Cap Impact

Modern HIV antiretroviral therapy involves daily oral medications that suppress the virus to undetectable levels. These drugs are not cheap — single-tablet regimens like Biktarvy cost approximately $40,000–$45,000/year at list price.

Before 2025, Medicare Part D beneficiaries paying for ART could face $3,000–$6,000+ in annual drug costs in the catastrophic phase. The 2025 $2,000 OOP cap fundamentally changes this:

• Maximum annual Part D drug spending: $2,000 (regardless of ART cost)
• The Medicare Prescription Payment Plan spreads the $2,000 over monthly installments
• For dual-eligible patients (Medicare + Medicaid), Extra Help further reduces costs

Long-Acting Injectable ART: Part B vs. Part D

A growing option for HIV treatment is long-acting injectable antiretroviral therapy, which eliminates the need for daily oral pills:

Cabenuva (Cabotegravir + Rilpivirine)

Given monthly or every 2 months in a healthcare setting, Cabenuva is physician-administered and covered under Part B at 20% coinsurance (not Part D). This means:

• For patients with Medigap Plan G: Cabenuva injections are effectively free (after Part B deductible)
• For patients without Medigap: 20% of $3,000–$5,000/month = $600–$1,000/month out of pocket
• Medigap Plan G is strongly recommended for patients considering Cabenuva

Lenacapavir (Sunlenca)

Given every 6 months by subcutaneous injection, lenacapavir is approved for multidrug-resistant HIV. Also covered under Part B as a physician-administered drug.

Ryan White Program: Coordination with Medicare

The Ryan White HIV/AIDS Program provides services to low-income people with HIV who are uninsured or underinsured. For Medicare beneficiaries, Ryan White can serve as a secondary payer — helping cover Medicare cost-sharing (deductibles, coinsurance) for HIV-related care.

Important points:

• Ryan White is the payer of last resort — Medicare pays first
• Ryan White may help with Part D premiums, deductibles, and cost-sharing for ART medications
• Eligibility is income-based; contact your local Ryan White grantee for details
• Ryan White does not replace Medicare — it supplements it for qualifying patients

With the 2025 $2,000 Part D OOP cap, the financial gap that Ryan White needs to fill is substantially smaller than in previous years.

HIV and Aging: Additional Medicare Considerations

People with HIV who are aging face a unique set of health concerns covered under Medicare:

• Cardiovascular disease: HIV and some older ART drugs increase CVD risk — cardiac screening and management covered under Part B
• Bone density: HIV and tenofovir can affect bone density — DEXA scans covered preventively under Part B
• Kidney disease: Some older ART drugs and HIV itself affect kidney function — monitoring covered under Part B
• Neurocognitive issues: HIV-associated neurocognitive disorder — neuropsychological testing covered under Part B
• Mental health: Depression and anxiety are highly prevalent in people with HIV — mental health services covered under Part B and Part D
• Cancer screenings: HIV increases risk of anal, cervical, and other cancers — relevant screenings covered

Frequently Asked Questions