PrEP Medication and Ancillary Services: Preventive Services Billing
Preventive care at $0 cost-share
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (“collectively” CareFirst) understands the importance of accessible preventive care.
Following updated guidelines from the U.S. Preventive Services Task Force (USPSTF), members who are at high risk of HIV infection may benefit from using pre-exposure prophylaxis (PrEP) medication with effective anti-retroviral therapy.
CareFirst encourages the use of PrEP when appropriate and has no prior authorization requirement for the generic drug, Truvada. CareFirst recommends monitoring of patients on PrEP consistent with the USPSTF guidelines, evidence-based medicine, and prescription labeling. All this care is preventive and, accordingly, CareFirst will waive all cost sharing. Here’s what’s included:
- HIV Testing: Screened before starting PrEP and every 3 months while taking PrEP. Services should be submitted as a preventive screening.
- Hepatitis B: Screened at baseline for initiation of PrEP. Services should be submitted as a preventive screening.
- Hepatitis C: Screened at baseline and periodically consistent with CDC guidelines for all individuals with ongoing risk of contracting Hepatitis C. Services should be submitted as a preventive screening.
- Creatinine Testing and calculated estimated creatine clearance (eCrCl) or glomerular filtration rate (eGFR): eCrCl or eGFR must be measured and calculated at beginning of treatment. Creatinine and eCrCl or eGFR should be checked periodically. Submit lab tests with preventive diagnostic code (Z113 or Z114).
- Pregnancy Testing: Before starting PrEP and periodically during treatment. Services should be submitted as preventive screening.
- Sexually transmitted infection screening and counselling and medication adherence follow-up visits: Use procedure codes 99401-99404 for counseling or follow-up visits, or preventive medicine codes 99381-99387 or 99391-99397 for comprehensive preventive visit.
See USPSTF guidelines for more information on evidence-based care guidelines for members who are at-risk for HIV infection.