CY 2026 Medicare Physician Fee Schedule Final Rule Summary

On October 31, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule and fact sheet for CY 2026 (CMS-1832-F). This rule updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP). The addenda, including Addendum B, which lists the final relative value units (RVUs) for each CPT® and HCPCS code can be found here. The list of codes subject to the negative 2.5% efficiency adjustment is included in the data files.

CMS finalized significant policy changes that align with the administration’s efforts to curb fraud, waste, and abuse, and advance the agency’s Make American Healthy Again initiative. Some of the changes include new payment policy to negatively adjust work RVUs account for efficiency gains over time, creation of policy to cut practice expense amounts for services performed in the facility setting, expansion of behavioral health initiatives, and making permanent changes to some telehealth provisions.

Note that the page numbers listed in this document refer to the of the display copy final rule. Also, new CPT codes now have final code numbers assigned.

Read ASH Comment Comparison 

Regulatory Impact Analysis

Conversion Factor for 2026
2026 marks the first year that there are two separate conversion factors: one for practitioners working in a qualifying advanced alternative payment model (APM) and the other for those not in a qualifying APM. The conversion factor for the former will increase to $33.57, an increase of 3.77%, and the latter to $33.40, an increase of 3.62%. These increases reflect the 2.5% increase to the conversion factor included in the reconciliation package adopted by Congress in July, and a 0.49% positive update to account for the redistributive effects of the finalized changes to work RVUs.

Specialty Level Impact of the Final Policy Changes – p. 1,738
CMS finalized two policies, an indirect practice expense calculation which creates a site of service payment differential and an efficiency adjustment, which place downward pressure on physician payment, even though Congress passed a 2.5% positive update to the conversion factor in 2026. Additionally, CMS has chosen to not use the new American Medical Association (AMA) Physician Practice Information Survey (PPIS) data for 2026 rate setting. The final policies lead to substantial variations in the impact percentages for both facility and non-facility (office) sites of service, with the office setting seeing positive changes to payment for certain physician services, while payment for physician services provided in the inpatient setting is reduced.

Table D-B7 of the rule (Appendix A of this summary) estimates the specialty level impacts of the policies included in the final rule and includes impacts of rate-setting changes and changes to RVUs within the budget neutral system. The impact of the final rule’s policies on group practices and individual physicians varies based on practice type, site of service, and the mix of patients and services provided.

Development of Strategies for Updates to Practice Expense Data Collection and Methodology – p. 53

Highlight: CMS thanks commenters for information on the AMA PPIS data for rate setting and remains interested in collecting data and cost shares information.

CMS is not using the AMA’s Physician Practice Information Survey (PPIS) survey data for rate setting calculations. Instead, the agency will maintain the current practice expense per hour (PE/HR) data and cost shares for 2026 rate setting. The agency reiterated reasons for not incorporating the updated PPIS data including low survey response rates and lack of representativeness, small sample size, lack of comparability to previous survey data, and missing or incomplete survey submissions. As background, the PE/HR is the estimated cost per hour of operating a medical practice and varies from specialty to specialty. The PE/HR includes direct practice expenses like clinical staff wages, medical supplies, equipment and indirect expenses like rent, utilities, and administrative costs. The AMA RUC uses the PPIS to inform their recommendations to CMS regarding the practice expense component of a service’s total RVUs. Given that CMS will not use updated AMA PPIS data to update the PE/HR rates for each physician specialty, the PE/HR will remain at 2017 levels.

Updates to Practice Expense (PE) Methodology – Site of Service Payment Differential – p. 68

Highlight: Indirect practice expense RVUs for physician services performed in the facility setting will be cut by 50% under final policy.

CMS finalized payment methodology reducing indirect practice expenses (PE) by 50% within the physician payment formula. The policy states that for each service valued in the facility setting under the MPFS, the agency will reduce the portion of the facility PE RVUs allocated based on work RVUs to half the amount allocated to nonfacility PE RVUs beginning in CY 2026. According to the agency, this new policy reflects the current state of clinical practice with fewer physicians working in private practice settings, and therefore, “the allocation of indirect costs for PE RVUs in the facility setting at the same rate as the non-facility setting may no longer reflect contemporary clinical practice.”

This policy reallocates Medicare payments away from physicians who deliver services in facility-based settings and toward those who provide care in office or outpatient settings. Knowing how Medicare defines a “place of service” is critical for understanding how this policy will affect a physician’s reimbursement.

Examples of facility-based settings include inpatient hospitals, on-campus and off-campus outpatient departments, hospital emergency rooms, and ambulatory surgical centers. Examples of non-facility settings include physician offices, patients’ homes or private residences, assisted living facilities, pharmacies, and urgent care centers. A full list of place-of-service codes is available in the Medicare Claims Processing Manual, Chapter 12, Section 20.4.2.

The rule notes that an increasing number of physicians do not own their practices and are employed by hospitals, and therefore the indirect costs should not be the same in both the facility and non-facility setting. The agency does recognize that there are some indirect costs for physicians who are solely based in the facility setting like coding, billing, and scheduling activities. However, the agency does not believe that these indirect PE costs are the same for facility and non-facility-based physicians, and therefore, believes that cutting the indirect PE amounts in the facility setting by 50% will more accurately account for the costs incurred in each setting of care. The agency does agree that physicians do incur some indirect costs for services provided in the facility setting stating that “this is why we retained allocating significant amounts of indirect PE RVUs per work RVUs in the facility setting.” The agency believes that 50% is an overpayment for the indirect costs incurred in facility settings.

Finally, this change will not be phased-in over a four-year period as the agency has done for prior significant changes to the practice expense methodology. The agency notes that phasing in the policy would only allow distortions of site-of-service payments to continue, and delay increases to payments made for non-facility services.

Efficiency Adjustment – p. 182

Highlight: CMS finalizes controversial efficiency adjustment (i.e., payment cut) for nearly all services on the physician fee schedule and continues to take aim at the AMA RUC process.

CMS finalized the efficiency adjustment aimed at improving the accuracy of work RVUs and intraservice physician time estimates for non-time-based services. Specifically, CMS will apply an efficiency adjustment of –2.5% to the work RVUs and intraservice time for nearly all services on the MPFS including procedures, radiology services, and diagnostic tests. The adjustment will not apply to time-based services, including evaluation and management (E/M) visits, behavioral health services, maternity global codes, and care management services. In response to comments from stakeholders, new CPT codes (i.e., those effective January 1) will not be subject to the efficiency adjustment in 2026. Table 1 illustrates an example as to how the work RVUs and intraservice time of surgical procedures are reduced through the efficiency adjustment. Although the reductions may appear small for each individual code, the cumulative impact over the course of a year will significantly affect overall reimbursement. Other services subject to the efficiency adjustment are listed here: Code List 2026.

Table 1. Effects of the Efficiency Adjustment Policy

Per CMS, the efficiency adjustment is meant to account for efficiency gains over time as practitioners become more skilled at performing procedures, and therefore, are performing those procedures faster than the intraservice times recommended by the RUC and used by CMS in rate setting. The agency continues to believe that the RUC survey process is flawed due to low response rates and the perceived conflicts of interest of those who take RUC surveys and reiterated this stance in the final rule. Additionally, throughout the responses to comments, CMS repeats that they welcome empiric data to support the value of physician services, which is yet another indication that CMS does not want to rely solely on RUC survey data to set payment rates. CMS states “we believe that robust empiric data is important to avoid some of the shortcomings of survey data in accounting for efficiencies over time.”

Many commenters stated that intraservice times are in fact increasing, contrary to CMS’s position, due to ever increasing patient complexity created by increased average body mass index and a higher number of chronic conditions per patient. To counter this comment, the agency reminds stakeholders that there are codes that may be used to report services for care management and care coordination for patients with complex health needs which could be used to account for increasingly complex patients. It may be inferred that the agency believes that the use of CPT codes associated with non-complex and complex care management (CCM) and principal care management (PCM) can fill the gap left by efficiency adjustment.

The agency was persuaded by comments to remove diagnostic, prophylactic, or therapeutic intravenous infusion services from the efficiency adjustment code list. Stakeholders noted that infusion rates are recommended on the required FDA labeling for chemotherapy and other infusion drugs, and therefore cannot become more efficient or delivered at faster rate. However, the agency did not say the codes would be removed permanently indicating in the rule that “we are removing time-based, drug administration codes from the list of codes to which the efficiency adjustment will apply in CY 2026. Stakeholders will need to remain vigilant to ensure the codes for these services are not added to the list for 2027.

To determine the percentage of the efficiency adjustment, the –2.5% was derived from the five-year cumulative productivity adjustment embedded in the Medicare Economic Index (MEI), which CMS believes reflects a reasonable approximation of the efficiency gains throughout services on the MPFS. The MEI is “a measure of inflation faced by physicians with respect to their practice costs and general wage levels, and includes inputs used in furnishing physicians’ services such as physician’s own time, non-physician employees’ compensation, rents, medical equipment, and more.” This is important to note because comments submitted specifically call out that it is unreasonable for CMS to use the MEI and productivity adjustment to determine if an efficiency adjustment is warranted when the physician fee schedule does not have associated yearly payment increases, quite unlike other payment systems in the Medicare program. CMS was again unmoved by these arguments and will finalize the policy. CMS will use the MEI to revise the efficiency adjustment as needed and will update the adjustment amount every three years. That means the efficiency adjustment may not be -2.5% in three years’ time, it could be higher or lower.

Geographic Practice Cost Indices (GPCIs) – p. 560

Highlight: Updated GPCI data will be phased in over two years.

CMS finalized updates to the GPCIs using more current data on wages, rent, equipment, and insurance to better reflect local cost differences and will continue to use existing MEI cost share weights for practice expense calculations in 2026.CMS finalized new GPCIs as proposed, to be phased in over two years beginning in CY 2026. In addition, CMS finalized the geographic adjustment factor (GAF) for each PFS locality.

Addenda D and E list the final CY 2026 GPCIs and GAFs by state and Medicare locality. For more information and a detailed explanation of the GPCIs, see page 560 of the final rule.

Potentially Misvalued Services Under the Physician Fee Schedule – p. 85

Each year the agency reviews potentially misvalued services. The criteria to identify a misvalued service are applied at the code level, and refinements are proposed by CMS for each code deemed misvalued. The review of values for the CPT code set is required by law, and since 2009, CMS has reviewed more than 1,700 codes.

Mechanical Separation of Plasma from Blood (CPT code 36514) – p. 111

An interested party nominated CPT code 36514 (Therapeutic apheresis; for plasma pheresis) as potentially misvalued stating the code is undervalued due to incorrect equipment utilization assumptions and price of the cell separator system practice expense input, and the assigned clinical labor code of RN/OCN which undervalues the therapeutic apheresis nurse operating wage costs. The agency disagrees with the nominator, as such the code will not be classified as misvalued.

Payment for Medicare Telehealth Services under Section 1834(m) of the Act – p. 135

Highlight: CMS modified the process to add services to the telehealth list and made permanent direct supervision of incident-to services.

Modification of the Medicare Telehealth Services List and Review Process – p. 136
CMS finalized the proposal to simplify the telehealth review process by removing steps 4 and 5 of the review process and focusing on whether a service can be furnished using an interactive telecommunications system. Step 4 had previously assessed whether the elements of the requested service map to those of services on the list with permanent status, while step 5 had previously assessed whether there is evidence of clinical benefit analogous to the clinical benefit of the in-person service when the patient receives the service by telehealth. The agency believes that the complex professional judgment of the physician or practitioner is sufficient to ensure that a service can be safely furnished via telehealth and that the service will be clinically beneficial to the patient. Moving forward, services on the Medicare Telehealth Services List will be included on a permanent basis; there will no longer be a provisional basis for including services. The process and decision-making parameters that the agency uses to make determinations as to whether a code(s) may be placed on the telehealth service list is found on page 139 of the final rule.

Requests to Add Services to the Medicare Telehealth Services List for CY 2026
The agency received several requests to add services to the Medicare Telehealth Services List, which can be found in Table A-D1, page 143 in the final rule.

Home INR Monitoring – p. 150
CMS received a request to add Home INR Monitoring (HCPCS Code G0248) to the Medicare Telehealth Services List. The agency is not adding this service to the list, as it finds that this is not a service that is generally furnished via a telecommunications system by a physician or practitioner; instead, clinical staff primarily provides the service.

Telemedicine E/M Services – p. 151
CMS received a request to add the telemedicine E/M services (CPT 98000-98015) to the Medicare Telehealth Services List. Since these services are not separately payable under the Medicare PFS and are assigned service indicator I (not valid for Medicare purposes), the agency is not adding these services.

Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations – p. 154
CMS will permanently remove frequency limitations on furnishing services via telehealth for the codes listed on page 156 of the final rule relating to subsequent inpatient visits, subsequent nursing facility visits, and critical care consultation services. The agency reiterates that physicians and practitioners can use their complex professional judgment to determine whether they can safely furnish a service by telehealth.

Direct Supervision via Use of Two-way Audio/Video Communications Technology – p. 158
CMS will permanently allow certain services to be furnished under direct supervision that allows the immediate availability of the supervising practitioner using audio/video real-time communications technology (excluding audio-only). This would apply to all services provided incident-to a physician services, except for services with a global surgery indicator of 010 or 090. The agency will apply this definition to the applicable cardiac, pulmonary, and intensive cardiac rehabilitation services.

Telehealth Originating Site Facility Fee Payment Amount Update – p. 170
For CY 2026, the final payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is $31.85.

Distant Site Requirements – p. 162
CMS received comments requesting that the agency provide clarification on policies related to telehealth. Several commenters expressed concern with the expiration of the flexibility for telehealth practitioners to use their currently enrolled address instead of their home address. The agency issued a FAQ that provides additional information on how to suppress street address details as providers continue to use their currently enrolled practice location instead of their home address and does not believe that additional extensions are required through rulemaking. Any future updates to this policy will be made through subregulatory guidance.

Evaluation and Management (E/M) Visit Complexity Add-on – p. 414

Highlight: CMS expands use of G2211 allowing its use with home and residence E/M services

The agency broadened the applicability of HCPCS code G2211(Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to home or residence or office/outpatient evaluation and management service, new or established) to include home and residence-based E/M visits.

CPT codes captured in this E/M code family include 99341, 99342, 993444, 99345, 99347, 99348, 99349, and 99350. The agency heard from stakeholders that home and residence visits are “high-touch” and involve the development of longitudinal relationships, which is a critical component required for billing G2211. Many homebound patients are often seen on a monthly or weekly basis due the nature or seriousness of their illnesses. This frequent interaction leads to the development of a trusted, longitudinal relationship between the provider and the patient.

Policies to Improve Care for Chronic Illness and Behavioral Health Needs – p. 436

Comments for Payment Policy for Software as a Service – p. 447
CMS notes that there has been a rapid development in the use of software-based technologies to support clinical decision-making in the outpatient and physician office setting, some of which may be devices that require FDA clearance, approval, or authorization, which is referred to in the rule as software as a service (SaaS). These technologies often incorporate software algorithms and AI, which are not accounted for in the current PE methodology. One example is the Fractional Flow Reserve Computed Tomography (Heartflow), which the agency allowed for limited separate MPFS payment of in CY 2022.

CMS requested comment on how to consider paying for SaaS under the MPFS. The agency appreciated the feedback from commenters and may consider for future rulemaking.

Request for Information on Prevention and Management of Chronic Disease – p. 450

In response to the Executive Order on “Establishing the President’s Make America Healthy Again Commission,” the agency is focused on the prevention and management of chronic diseases as a top priority. The agency requested feedback on how to enhance support for the prevention and management of chronic disease, including through proposals that increase physical activity, access to medically tailored meals, and reimbursement for intensive behavioral therapy.

CMS sought feedback on creating additional coding and payment for motivational interviewing, which is defined as a collaborative, goal-oriented style of communication with particular attention to the language of change. The agency appreciates the feedback received and will consider the comments for potential future rulemaking.

Social Determinants of Health Risk Assessment - HCPCS code G0136 - 460

Highlight: CMS does not delete G0136 but instead reframes the data to be captured by the code.

CMS proposed to delete HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes, not more often than every 6 months) created by the agency in 2024 to capture work and provide payment for services associated with the administration of a standardized, evidenced based social determinants of health risk assessment tool. The agency stated that the work associated with G0136 may already be accounted for in other types of services like evaluation and management visits.

However, after considering stakeholder comments, CMS has decided to keep HCPCS code G0136 and replace the terms evidenced-based social determinants of health risk assessment with physical activity and nutrition. The code’s descriptor now reads - Administration of a standardized, evidence-based assessment of physical activity and nutrition, 5-15 minutes, not more often than every 6 months. This change, per CMS, refocuses the goal of the type of assessment that must be conducted to report this service and is intended to support CMS’ efforts to address the root causes of chronic disease through the evaluation of essential lifestyle factors. Per the agency “while the root causes of chronic disease are often multi-factorial and holistic, tailored interventions may be optimal, and assessing risk related to the root causes of many chronic conditions begins with assessing essential, common behaviors such as physical activity levels and nutrition (that is, diet composition).”

CMS emphasizes that this assessment should be used to inform the diagnosis and treatment plan during an associated E/M or behavioral health visit, and practitioners are expected to incorporate the results into their medical decision-making and refer patients to relevant resources. The service has a work RVU of 0.18 and may be provided via telehealth.

Community Health Integration (CHI) Services - HCPCS Code G0019 p. 465

Highlight: CMS removes the term “social determinants of health” from the code descriptor for G0019.

Effective January 1, 2026 CMS will replace the term “social determinants of health” with the term “upstream drivers of health” in the descriptor for HCPCS code G0019 (Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month, in the following activities to address upstream driver(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating visit). CMS believes the term upstream drivers “encompasses a wider range of root causes of the problems that practitioners are addressing through CHI services. This type of whole-person care can better address the upstream drivers that affect patient behaviors (such as smoking, poor nutrition, low physical activity, substance misuse, etc.) or potential dietary, behavioral, medical, and environmental drivers to lessen the impacts of the problem(s) addressed in the CHI initiating visit.”

Provisions on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Services – p. 471

Highlight: No dental services will be added to the agency’s list of dental services inextricably linked to other covered services.

Submissions Received Through Public Submissions Process
The agency received seven submissions to be considered as dental services that are inextricably linked to, and substantially related and integral to the clinical success of other clinical services. Many of the submissions recommended clinical scenarios involving diabetes mellitus, particularly around the impact of dental infections on diabetes-associated retinopathy and nephropathy. Another submitter included additional information related to autoimmune disease and oral health.

For CY 2026, the agency is not making any proposals in response to the received submissions and will take the information and recommendations into consideration for future rulemaking.

Drugs and Biological Products Paid Under Medicare Part B – p. 589

Highlight: CMS finalized a definition of bundled arrangement and updated requirements for ASP data submissions.

Average Sales Price: Price concessions and bona fide services fees
Drugs payable under Medicare Part B fall into three categories: 1) those furnished incident-to a physician’s services; 2) those furnished via a covered item of durable medical equipment; and 3) other drugs for which coverage is specified by statute, such as vaccines. For most drugs separately paid under Medicare Part B, payment is based on the average sales price (ASP) plus a 6% add-on.

As part of the calculation of the manufacturer’s ASP, the manufacturer must deduct price concessions such as volume discounts, prompt pay discounts, cash discounts, free goods that are contingent on any purchase requirement, chargebacks, and rebates. However, bona fide service fees (BFSFs) are not considered price concessions and are not deducted when calculating the manufacturer’s ASP. BSFS’s are defined as fees paid by a manufacturer to an entity that represents the fair market value for an itemized service performed on behalf of the manufacturer, and the fees are not passed on to the client.

CMS is concerned that there may be discrepancies in how manufacturers define BFSF’s and what is a concession. However, after receiving feedback from commenters, the agency did not move forward with regulatory text to specify when certain fees are considered price concessions, or the proposed revised definition of BFSFs. The agency will encourage manufacturers to document in their reasonable assumptions which service fees are tied to costs that do not depend on the drug’s price or volume, and which service fees do. The agency did not finalize the proposal to assess fair market value (FMV) methodology standards, reassessments, and independent third-party valuator requirements.

CMS finalized a proposal to require manufacturers to submit reasonable assumptions that they utilize for ASP calculations, as well as requiring manufacturers to submit a warranty or certification from the recipient of a fee that it is not passed on in whole or in part. The agency will provide a template of the reasonable assumptions letter for manufacturers to document FMV analyses.

CMS finalized a definition of the term “bundled arrangement” to state that “bundled arrangement means an arrangement regardless of physical packaging under which the rebate, discount, or other price concession is conditioned upon the purchase of the same drug or biological or other drugs or biologicals or another product or some other performance requirement (for example, the achievement of market share, inclusion of tier placement on a formulary), or where the resulting discounts or other price concessions are greater than those which would have been available had the bundled drugs or biologicals been purchased separately or outside the bundled arrangement.” To remain consistent with the Medicare Drug Rebate Program, the agency removed “purchasing patterns” and “prior purchases” from the definition in the proposed rule. CMS plans to further implement this policy area in rulemaking next year.

Autologous Cell-based Immunotherapy and Gene Therapy Payment – p. 629

Highlight: CMS, unwilling to make separate payment for the work associated with certain steps in the delivery of CAR T-cell therapy, continues to assert that these steps are a part of the manufacturing process.

With this rule, CMS affirmed existing policy not to make separate payment for the steps involved in harvesting blood-derived T lymphocytes (CPT code 38225), preparation of T lymphocytes for transportation, including cryopreservation, and storage (CPT code 38226) and preparation of CAR T-cells for administration (CPT code 38227). The agency will continue to provide payment for the services associated with the administration of CAR T-cells (CPT code 38228). The agency states that “Medicare does not generally pay separately for each step used to manufacture a drug or biological.” Not only is CAR T-cell therapy captured here, but CMS finalized that all preparatory procedures associated gene therapy are also bundled into the payment for the therapy product itself, rather than reimbursing each step separately. This includes tissue collection and associated manufacturing activities. CMS views these steps as integral to the manufacturing process of the product, not distinct reimbursable activities. The Society along with other stakeholders submitted comments outlining reasons that this is not sound policy, urging the agency to reconsider. Additionally, CMS is not moving forward with its proposal to require inclusion of preparatory procedures in Average Sales Price (ASP) reporting starting in 2026.

Finally, as a direct result of comments submitted the Society, the payment status indicator for services reported by CPT code 38228 (CAR-T cell administration) will be corrected. In current payment files the status indictor for 38228 is noted as an “incident to” service (PC/TC indicator 5). ASH comments clarified that the service involves direct physician supervision and personally supervises the initiation of product infusion, and that the assigned status indicator of 5 is likely a technical error. CMS acknowledged this as a technical error and is correcting the PC/TC indicator to “0” for CY 2026.

Medicare Prescription Drug Inflation Rebate Program – p. 1,146

Highlight: CMS finalizes policies to implement the Medicare Prescription Drug Inflation Rebate Program.

Overview of the Medicare Prescription Drug Inflation Rebate Program
Sections 11101 and 11102 of the Inflation Reduction Act established requirements that drug manufacturers must pay inflation rebates if they raise their prices for certain drugs payable under Part B and/or covered under Part D faster than the rate of inflation.

CMS finalized the proposal to describe how the agency would identify the payment amount in the benchmark quarter if data were unavailable to calculate the payment amount in that quarter. CMS also finalized policy to calculate the payment amount if there is no published payment limit and neither positive ASP nor positive Wholesale Acquisition Cost (WAC) data are available in the ASP Data Collection System.

Under Section 428.203(b)(2), for claims with dates of service on or after January 1, 2026, CMS will exclude from the total number of units used to calculate the total rebate amount for a Part D drug those units for which a manufacturer provided a discount under the 340B program. CMS finalized the proposal to use a claims-based methodology to implement this section.

CMS established a 340B repository to receive voluntary submissions from 340B covered entities of certain data elements from Part D 340B claims.

Drugs Covered as Additional Preventive Services (DCAPS)
Starting on September 30, 2024, CMS established coverage of Preexposure Prophylaxis (PrEP) using antiretroviral therapy to prevent HIV infection as an additional preventive service under the Social Security Act, which is referred to as DCAPS. CMS finalized the proposal to identify DCAPS as Part B rebatable drugs and will calculate rebates based on the current methodology.

Appendix A: CY 2026 PFS Estimated Impact on Total Allowed Charges by Specialty – p. 1,738