25-913 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)
Date: 09/05/25
Avoid claims payment delays by using accurate coding
The California Department of Managed Health Care (DMHC) issued All Plan Letter (APL) 25-011 (PDF) on May 23, 2025, as a reminder about how PrEP drugs are covered.1
What this means for you and delegated PPGs
- Health plans and entities delegated for claims payment, such as delegated participating physician groups (PPGs), must cover all PrEP medications approved by the U.S. Food & Drug Administration (FDA) without cost sharing.
- Prior authorization and step therapy are not allowed for these medications, except when the FDA has approved one or more therapeutic equivalents to a drug. In that instance, Health Net does not need to cover all the therapeutically equivalent versions of the drug without prior authorization or step therapy, if Health Net covers at least one therapeutically equivalent version without prior authorization or step therapy.
- In addition to the antiretroviral drug itself, the Plan must also cover all integral services necessary for PrEP initiation and ongoing follow-up care and monitoring, as specified in clinical guidance issued by the Centers for Disease Control and Prevention (CDC).
Billing and coding
To prevent members from being inadvertently charged cost-sharing for PrEP and/or services integral to the administration of PrEP, the Plan, physicians and other providers should follow the uniform coding guidelines consistent with ICD-10-CM and any updates to it.
Below are two tables that can help you bill correctly. The first sets forth integral services recommended by the CDC for daily oral PrEP and the second pertains to long-acting injectable PrEP and cabotegravir. With respect to each form of PrEP, the listed integral services must all be covered as preventive care without cost-sharing. Each chart includes the CDC-recommended frequency for each integral service.
If an insurer imposes frequency limits on any integral services for PrEP, the frequency limits must not be more restrictive than those set forth in the CDC’s guidelines. The charts also include examples of billing codes for integral services. The billing codes included in the charts are not intended to be a complete list of qualifying codes.
Daily oral PrEP
Per the ICD-10-CM guidelines, the primary/first position code should be Z29.81 for each service provided as part of the PrEP protocol. The specific tests and services provided should then be coded as shown in the following table.
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Integral services recommended by the CDC for daily oral PrEP
CDC-recommended | CPT® code examples | CDC recommended frequency |
|---|---|---|
Encounter for prescribing (up to 90-day supply), adherence and behavioral risk reduction counseling, medication management | Preventive medicine counseling: 99401-99404, 99411, 99412 | At baseline and at least every 3 months thereafter |
HIV screening test | 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87806 | At baseline and at least every 3 months thereafter |
Hepatitis B virus screening | 86704-86706, 87340, 87341, 87467 | At baseline |
Hepatitis virus vaccination | 90743, 90746 | At baseline |
Hepatitis C virus screening | 86803, 86804 | At baseline and every 12 months thereafter |
Renal function testing | 82565, 82570, 82575 | At baseline and at least every 6 (age 50+) to 12 (age < 50) months thereafter |
Gonorrhea, chlamydia, and syphilis screening for men and transgender women who have sex with men | Gonorrhea: 87590, 87591, 87592, 87850 | At baseline and at least every 3 months thereafter |
Gonorrhea and syphilis screening for heterosexually active men and women | Gonorrhea: 87590, 87591, 87592, 87850 | At baseline and at least every 6 months thereafter |
Chlamydia screening for heterosexually active women and men | 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 | At baseline and at least every 12 months thereafter |
If on tenofovir disoproxil fumarate (F/TDF), triglyceride and cholesterol level monitoring | 80061 | At baseline and at least every 12 months thereafter |
Pregnancy testing | 81025, 84702, 84703 | At baseline and as necessary |
- Other codes that may be relevant include: 80081; G0432; G0433; G0435; G0475, G0011, G0012 - G0013 (only covered by Medicare), J0750, J0751, J0799.
- Please note that the CDC recommended frequency is not a bright line rule. The appropriate frequency of a particular service for an enrollee will depend on the individual circumstances of the enrollee.
Long-acting injectable PrEP
Per the ICD-10-CM guidelines, the primary/first position code should be Z29.81 for each service provided as part of the PrEP protocol. The specific tests and services provided should then be coded as shown in the following table.
Coding for specific tests and services
CDC-recommended | CPT code examples | CDC recommended frequency |
|---|---|---|
Encounter for injection, adherence and behavioral risk reduction counseling, medication management | Preventive medicine counseling: 99401-99404, 99411, 99412 | At baseline, 4 weeks later, and every 8 weeks thereafter (months 0, 1, 3, 5, etc.) |
Cabotegravir | HCPCS Code J0739 | At baseline, 4 weeks later, and every 8 weeks thereafter |
HIV screening test | 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87806 | At baseline, 4 weeks later, and every 8 weeks thereafter |
Hepatitis C virus screening | 86803, 86804 | At baseline and every 12 months |
Gonorrhea, chlamydia, and syphilis screening for men and transgender women who have sex with men | Gonorrhea: 87590, 87591, 87592, 87850 | At baseline and at least every 4 months |
Gonorrhea and syphilis screening for heterosexually active men and women | Gonorrhea: 87590, 87591, 87592, 87850 | At baseline and at least every 6 months |
Chlamydia screening for heterosexually active women and men | 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 | At baseline and at least every 6 months |
Pregnancy testing | 81025, 84702, 84703 | At baseline and as needed |
- Please note that the CDC recommended frequency is not a bright line rule. The appropriate frequency of a particular service for an enrollee will depend on the individual circumstances of the enrollee.
Access the APL online
For more information, view APL 25-011 on the DMHC’s website. Go to the DMHC’s website > All Plan Letters > Guidance & information to health plans regulated by the DMHC.
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
Provider Services
Line of business | Phone number | |
|---|---|---|
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medi-Cal (including CS and ECM providers) | N/A |
1Information in this notice has been taken or derived from APL 25-011 - Health Plan Coverage of HIV Preexposure Prophylaxis (PrEP)(PDF).
This information applies to delegated Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.