Payment Allowances for HIV PrEP Codes
Palmetto GBA has established payment allowances for Healthcare Common Procedure Coding System (HCPCS) codes related to pre-exposure prophylaxis (PrEP) using antiretroviral therapy to prevent human immunodeficiency virus (HIV) infection. The fees detailed below are effective September 30, 2024, through December 31, 2024.
| Code | Description | Fee |
|---|---|---|
| J0739 | Injection, cabotegravir, 1 mg, FDA-approved prescription, only for use as HIV PrEP (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 PrEP (not for use as treatment of HIV) | $1.233 |
| J0751 | Emtricitabine 200 mg and tenofovir alafenamide 25 mg, oral, FDA-approved prescription, only for use as HIV PrEP (not for use as treatment of HIV) | $75.612 |
| J0799 | FDA-approved prescription drug, only for use as HIV PrEP (not for use as treatment of HIV), not otherwise classified | Priced Individually |
| Q0516 | Pharmacy supplying fee for HIV PrEP FDA-approved prescription oral drug, per 30-days | $16.00 |
| Q0517 | Pharmacy supplying fee for HIV PrEP FDA-approved prescription oral drug, per 60-days | $16.00 |
| Q0518 | Pharmacy supplying fee for HIV PrEP FDA-approved prescription oral drug, per 90-days | $16.00 |
| Q0519 | Pharmacy supplying fee for HIV PrEP FDA-approved prescription injectable drug, per 30-days | $16.00 |
| Q0520 | Pharmacy supplying fee for HIV PrEP FDA-approved prescription injectable drug, per 60-days | $16.00 |
J0799
When submitting claims for J0799, please provide the National Drug Code (NDC) for the product being provided, the drug name, and dose provided on the claim. Additional documentation may be required to support coverage and/or to price drugs billed as J0799.
Additional Resources
- Unclassified or Not Otherwise Classified (NOC) Drug Codes: Rejected if Not Submitted Correctly
- Electronic Claims and Additional Documentation
| Code | Description |
|---|---|
|
G0012 |
Injection of PrEP drug for HIV prevention, under skin or into muscle |
Pricing for these codes can be found on the Medicare Physician Fee Schedule.
Additional Resources
| Code | Description |
|---|---|
| G0011 | Individual counseling for PrEP by physician or qualified health care professional (QHP) to prevent HIV, includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence, 15–30 minutes |
| G0013 | Individual counseling for PrEP by clinical staff to prevent HIV, includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence |
Pricing for these codes can be found on the Medicare Physician Fee Schedule.
Additional Resources