Pre-exposure prophylaxis (PrEP) using antiretroviral drugs to prevent human immunodeficiency virus (HIV) infection
Medicare now covers PrEP to prevent HIV in individuals at increased risk of getting HIV, without cost-sharing (e.g., deductibles or co-pays for people with Medicare Part B). A physician or health care practitioner who assesses the patient's history determines whether they are at increased risk for HIV.
If assessing your patients for PrEP to prevent HIV, or they are using it, Medicare covers the following as an additional preventive service:
- Up to eight individual counseling visits every 12 months
- Up to eight HIV screening tests every 12 months
- Single screening for hepatitis B virus
Notes
- If a physician or health care practitioner buys an injectable PrEP drug, submit claims to First Coast (A/B MAC)
- Pharmacies can bill for PrEP for HIV drugs if they are enrolled as one of the following:
- DMEPOS supplier, submit claims to DME MAC
- Part B pharmacy supplier, submit claims to First Coast (A/B MAC)
- If a physician or health care practitioner prescribes PrEP drug, at least one valid ICD-10 diagnosis code should be included to help pharmacies submit their claims. There are multiple diagnosis codes that may be appropriate, including codes for:
- Encounter for HIV pre-exposure prophylaxis
- Encounter for screening for human immunodeficiency virus
- Increased risk factors
- Two new HCPCS codes have been established effective October 1, 2025:
- J0738: Injection, lenacapavir, 1 mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV)
- J0752: Oral, lenacapavir, 300 mg, FDA approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV)
Pharmacy claims
CMS added a new HCPCS code (Q0521- Supply fee HIV prep FDA appr) for pharmacies billing for PrEP for HIV drugs, effective January 1, 2025.
The new code replaces codes Q0516, Q0517, Q0518, Q0519, and Q0520.
References