October 4, 2024 – Updated 12.31.24
Payment Allowances for PrEP Using Antiretroviral Therapy to Prevent HIV Infection
Effective September 30, 2024, CMS will cover pre-exposure prophylaxis (PrEP) using antiretroviral drugs approved by the U.S. Food and Drug Administration (FDA) to prevent human immunodeficiency virus (HIV) in individuals at increased risk of HIV acquisition.
The table below shows the approved HCPCS codes and payment allowances for dates of service September 30 – December 31, 2024.
See the CMS PrEP for HIV & Related Preventive Serviceswebsite for additional information and payment updates starting January 1, 2025.
HCPCS Code | Long Descriptor | Payment Allowance Effective September 30 – December 31, 2024 |
---|---|---|
Drug Codes | ||
G0012 | Injection of pre-exposure prophylaxis (prep) drug for hiv prevention, under skin or into muscle | See the Medicare Physician Fee Schedule |
J0739 | Injection, cabotegravir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv) | $6.741 |
J0750 | Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv) | $1.062 |
J0751 | Emtricitabine 200 mg and tenofovir alafenamide 25 mg, oral, fda approved prescription, only for use as pre-exposure prophylaxis (not for use as treatment of hiv) | $75.612 |
J0799* | FDA approved prescription drug, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv), not otherwise classified | Invoice* |
Counseling Codes | ||
G0011 | Individual counseling for pre-exposure prophylaxis (PrEP) by physician or QHP to prevent human immunodeficiency virus (HIV), includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence, 15-30 minutes | See the Medicare Physician Fee Schedule |
G0013 | Individual counseling for pre-exposure prophylaxis (PrEP) by clinical staff to prevent human immunodeficiency virus (HIV), includes: HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence | |
Pharmacy Supplying Fee Codes | ||
Q0516 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 30-days | $24.00 |
Q0517 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 60-days | $40.00 |
Q0518 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 90-days | $56.00 |
Q0519 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription injectable drug, per 30-days | $24.00 |
Q0520 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription injectable drug, per 60-days | $24.00 |
* For HCPCS code J0799, report the National Drug Code (NDC), drug name, and dose provided on the claim. We may require additional documentation to determine coverage or pricing. See Invoice Claim Filing Instructions for details.