This article is for providers prescribing HIV PrEP for our members
Please share with your billing
department or billing agency
We have updated our Patient Protection and Affordable Care Act (ACA) Preventive Care Services Billing Guideline to comply with the latest requirements for coverage.1
What’s new?
We now apply a $0 cost share to these FDA-approved PrEP medications for adolescents and adults:
- Apretude (injectable; covered under either medical benefit or pharmacy benefit)
- Descovy (brand name; covered as part of pharmacy benefit)
While we previously covered all three of these medications, emtricitabine/tenofovir disoproxil fumarate (the generic for Truvada) was the only medication covered at $0 cost share as part of the pharmacy benefit.
Billing for Apretude as a preventive service
Here are some tips for billing Apretude as a preventive service using the member’s medical benefit. Billing in this way helps avoid unnecessary claim denials and confusion for our members, so we suggest sharing this information with your billing department.
| Type of claim | Use this diagnosis code | The following drug/administration codes can be used |
|---|---|---|
| Facility or professional |
Z29.81
Bill in the primary position on the claim since our benefits for preventive, screening, counseling, or wellness services are based on the primary diagnosis |
J0739 (medication)
G0012 or 96372 (administration) |
Thank you.
As always, before performing services, please check the member’s eligibility and benefits.
MPC_071318-4C-10
1 Some grandfathered plan designs may not offer preventive care, including preventive medications, at $0 cost to the member.