Payment Allowances for HIV PrEP Codes

Published 10/08/2024

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. 

Table 1: Payment Allowances for Oral and Injectable HIV PrEP Codes.
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 

Table 2: Injection for PrEP Drug for HIV Prevention.
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

Table 3. PrEP for HIV Counseling.
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


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