This content is for health care providers. If you’re a person with Medicare, learn more about your Medicare coverage of HIV prevention services.
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This content is for health care providers. If you’re a person with Medicare, learn more about your Medicare coverage of HIV prevention services.
As of September 30, 2024, Medicare covers these services without cost-sharing (for example, deductibles or copayments under Part B) to decrease an individual's risk of acquiring HIV:
CMS covers HIV prevention services, including PrEP, for people with Medicare at increased risk of acquiring HIV. Physicians and health care practitioners assessing the individual’s history determine if an individual is at increased risk for HIV. To be eligible for counseling, individuals must be competent and alert during counseling.
People with Medicare don’t pay deductibles, copayments, or coinsurance.
Some people with Medicare may have previously gotten PrEP for HIV drug coverage through Part D and paid a deductible and coinsurance or copayments. As of September 30, 2024, Part B covers these drugs.
If an individual currently has HIV and uses antiretroviral drugs to treat HIV, Part D will continue to cover these drugs, even though these may be the same drugs that are used for HIV PrEP.
Help make sure people with Medicare have critical, uninterrupted access to HIV PrEP drugs:
Pharmacies can bill for PrEP for HIV drugs if they're enrolled as one of the following:
Check to see if you’re enrolled by entering the pharmacy’s NPI in the search bar. Even if you provide vaccines, you’re not necessarily enrolled in Part B.
There are multiple diagnosis codes that may be appropriate to use for HIV prevention services:
ICD-10 Codes (codes accepted on claims with dates of service on or after September 30, 2024):
ICD-10 Codes (codes accepted on claims with dates of service on or after April 7, 2025):
Original Medicare (Fee-for-Service) claims pharmacies submit must be processed by the DME MAC or the A/B MAC, depending on whether the pharmacy is enrolled as a DMEPOS supplier or a Part B supplier pharmacy. This includes claims for the oral or injectable HIV PrEP drugs and the pharmacy supplying fee. The MACs are pricing these codes through December 31, 2024. Note: Use the codes below through December 31, 2024. For codes starting January 1, 2025, see “How Do I Bill Starting January 1, 2025?” for more information.
Billing Codes for Pharmacy Suppliers
Code | Descriptor | Short Descriptor |
---|---|---|
J0739 | Injection, cabotegravir, 1mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV) | HIV prep, inj, cabotegravir |
J0750 | Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV) | HIV prep, ftc/tdf 200/300mg |
J0751 | Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV) | HIV prep, ftc/taf 200/25mg |
J0799 | FDA approved prescription drug, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV), not otherwise classified | HIV prep, FDA approved, noc |
Q0516 | Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription oral drug, per 30-days | Supply fee HIV prep oral 30 |
Q0517 | Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription oral drug, per 60-days | Supply fee HIV prep oral 60 |
Q0518 | Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription oral drug, per 90-days | Supply fee HIV prep oral 90 |
Q0519 | Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription injectable drug, per 30-days | Supply fee HIV prep inj 30 |
Q0520 | Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription injectable drug, per 60-days | Supply fee HIV prep inj 60 |
Billing Codes for Providers
Code | Descriptor |
---|---|
J0739 | Injection, cabotegravir, 1mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV) |
J0799 | FDA approved prescription drug, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV), not otherwise classified |
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 |
G0012 | Injection of pre-exposure prophylaxis (prep) drug for HIV prevention, under skin or into muscle |
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 |
If a pharmacy provides an injectable drug directly to the practitioner, the practitioner bills Part B for the PrEP for HIV drug (such as J0739 in a typical “buy and bill” approach). The pharmacy isn’t able to bill for the drug and, therefore, not able to bill a supply fee. We understand in such arrangements that the pharmacy may invoice the practitioner.
Starting January 1, 2025, Medicare pays for PrEP for HIV drugs according to the DCAPS (Drugs Covered as Additional Preventive Services) fee schedule. Original Medicare (Fee-for-Service) claims pharmacies submit must be processed by the DME MAC or the A/B MAC, depending on whether the pharmacy is enrolled as a DMEPOS supplier or a Part B supplier pharmacy. This includes claims for the oral or injectable HIV PrEP drugs and the pharmacy supplying fee.
Billing Codes for Pharmacy Suppliers
Code | Short Descriptor | Payment Limit |
---|---|---|
J0739 | HIV prep, inj, cabotegravir | View the ASP Drug Pricing Files |
J0750 | HIV prep, ftc/tdf 200/300mg | View the ASP Drug Pricing Files |
J0751 | HIV prep, ftc/taf 200/25mg | View the ASP Drug Pricing Files |
J0799 | HIV prep, FDA approved, noc | View the ASP Drug Pricing Files |
Q0521* | Supply fee HIV prep FDA appr | $24 (initial supply in a 30-day period) or $16 (additional supply in the same 30-day period) |
More information on using Q0521 to furnish PrEP:
Day(s) | Scenario | Payment |
1 | Furnish the drug for any duration (such as 30, 60, or 90 days) | $24 |
After Day 1 and Before Day 31 | A potential scenario can occur that results in a supplier or pharmacy furnishing an “additional supply.” Scenarios may include filling:
| $16 |
On or After Day 31 | Furnish the drug for any duration (such as 30, 60, or 90 days) | $24 |
Billing Codes for Providers
Code | Descriptor | Payment Limit |
---|---|---|
J0739 | Injection, cabotegravir, 1mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV) | View the ASP Drug Pricing Files |
J0799 | FDA approved prescription drug, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV), not otherwise classified | View the ASP Drug Pricing Files |
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 | View the Physician Fee Schedule |
G0012 | Injection of pre-exposure prophylaxis (prep) drug for HIV prevention, under skin or into muscle | View the 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 | View the Physician Fee Schedule |
* Codes G0011 and G0013 relate to counseling and aren’t on the DCAPS fee schedule. They’re included here for reference.
If a pharmacy provides an injectable drug directly to the practitioner, the practitioner bills Part B for the PrEP for HIV drug (such as J0739 in a typical “buy and bill” approach). The pharmacy isn’t able to bill for the drug and, therefore, not able to bill a supply fee. We understand in such arrangements that the pharmacy may invoice the practitioner.
If you want to bill for PrEP for HIV drugs, if you’re enrolled in Part B with the provider type “mass immunization,” you must still enroll as provider type “pharmacy” to bill for PrEP for HIV drugs.
RHCs and FQHCs don’t have to enroll as a “pharmacy” to bill for PrEP for HIV drugs.
For information on pharmacy enrollment, listen to this webinar or view the transcript.
1. Pre-Enrollment
2. Submit Your Provider Enrollment Application(s) to Your MAC(s)
3. What to Expect After Submitting Your Enrollment Application