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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 ServicesExternal Websitewebsite 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.

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