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New coverage criteria for HIV PrEP for Medicare Advantage members
October 15, 2024

This article is for providers caring for our Medicare Advantage members

CMS has issued its final coverage criteria for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. Based on this guidance, members of our Medicare Advantage plans will have coverage, effective immediately, for the following:

  • PrEP using antiretroviral drugs (whether oral or injectable) approved by the U.S. Food and Drug Administration (FDA) to prevent HIV infection in individuals at high risk of HIV acquisition.
  • Up to eight individual counseling visits, every 12 months, that include HIV risk assessment (initial or continued assessment of risk), HIV risk reduction, and medication adherence.
  • HIV screening up to eight times every 12 months and a single screening for hepatitis B virus (HBV) for individuals being assessed for, or who are taking, PrEP.

We will cover PrEP, the additional screening tests, and counseling services at a $0 cost-sharing preventive service when provided by an in-network provider.

Billing and payment codes for the other covered services related to HIV PrEP for claims may include:

Code Narrative
J0739 Injection, cabotegravir, 1mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV)
G0011 Individual counseling for pre-exposure prophylaxis (PrEP) by physician or QHP [qualified health professional] 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
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
G0012 Injection of pre-exposure prophylaxis (PrEP) drug for HIV prevention, under skin

Diagnosis codes are required for claims submitted to Medicare. A new diagnosis code recently became available (Z29.81: Encounter for HIV pre-exposure prophylaxis).

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