Pre-exposure Prophylaxis (PrEP) using antiretroviral therapy to prevent HIV infection
CMS has issued a final NCD for FDA-approved Pre-exposure Prophylaxis (PrEP) using antiretroviral drugs to prevent HIV infection. The payment allowances are below.
Allowances for Florida, Puerto Rico, and the U.S. Virgin Islands:
| Code | DOS on 9/30/2024 Part A and B |
DOS 10/1 – 12/31/2024 Part A |
DOS 10/1-12/31/2024 Part B |
|---|---|---|---|
| J0739 | 5.659 | 6.809 | 5.659 |
| J0750 | 1.03 | 4.870 | 1.03 |
| J0751 | 73.41 | 77.815 | 73.41 |
| Q0516 | 24.00 | N/A | 24.00 |
| Q0517 | 36.00 (B only) | N/A | 36.00 |
| Q0518 | 48.00 (B only) | N/A | 48.00 |
| Q0519 | 24.00 (B only) | N/A | 24.00 |
| Q0520 | 36.00 (B only) | N/A | 36.00 |
For the administration for dates of service from September 30 through December 31, 2024, for code G0012:
| Location | Par allowance | Non-par allowance | Limiting charge |
|---|---|---|---|
| FL 99 (01/02) | 13.97 | 13.27 | 15.26 |
| FL03 | 14.55 | 13.82 | 15.90 |
| FL04 | 15.04 | 14.29 | 16.43 |
| PR | 14.37 | 13.65 | 15.70 |
| USVI | 14.37 | 13.65 | 15.70 |