MedicaidCoverageMedium impact
25-915 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)
Health Net·CA · Family Medicine, Internal Medicine, Infectious Disease +1 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health plans must cover all FDA-approved HIV PrEP medications and integral services without cost sharing, prior authorization, or step therapy (except when therapeutic equivalents exist). Billing teams must use Z29.81 as the primary diagnosis code for all PrEP-related services and follow specific CPT coding guidelines for oral and injectable PrEP protocols.
Action Required
Immediately: Billing team must update coding protocols for HIV PrEP services to use Z29.81 as primary diagnosis code for all PrEP-related encounters. Create billing guidelines distinguishing between daily oral PrEP and long-acting injectable PrEP frequency requirements. Train staff on proper CPT code selection based on patient demographics and risk categories. Verify billing system removes prior authorization requirements for FDA-approved PrEP medications unless therapeutic equivalents exist.