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).
Resources
- Providers can learn more at cms.gov/medicare/coverage/prep.
- Members can learn more by going to our Medicare Options website.
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