October 4, 2024
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.
Refer to the National Coverage Determination (NCD) and CMS PrEP for HIV & Related Preventive Services website for additional information.
The following HCPCS codes are approved for HIV PrEP drugs and their administration or supplying:
HCPCS Code |
Long Descriptor |
Payment Allowance |
---|---|---|
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* |
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.
The following HCPCS codes are approved for PrEP for HIV counseling:
HCPCS Code |
Long Descriptor |
Payment Allowance |
---|---|---|
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 |