CMS Updates HIV PrEP Supply Fee Code, Effective 01/01/2025
In December 2024, PAAS National® brought you the Medicare Part B Coverage of HIV PrEP Newsline article which provided an in-depth look into appropriately billing HIV PrEP medications to Medicare Part B. The original shift from billing these medications from Medicare Part D to Part B was effective just a few months ago (September 30, 2024, to be precise), and CMS has already instituted a change to the supply fee HCPCS billing code.
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The left column of the table below shows the appropriate supply fee HCPCS codes and associated descriptions which were effective September 30, 2024, through December 31, 2024. The column on the right shows the new supply fee code effective January 1, 2025. In essence, one new supply fee code replaced the five original supply fee codes. For pharmacies that utilize a third-party billing intermediary for their Medicare Part B claims, this change will undoubtedly occur in the background as the pharmacy claim date is “translated” into medical claim data by the intermediary.
| Pharmacy Supply “Dispensing” Fee Through 12/31/2024 | Pharmacy Supply “Dispensing” Fee Starting 01/01/2025 | |||
| HCPCS Code | Description | HCPCS Code | Description | |
| Q0516 Q0517 Q0518 | Oral drug, per 30-days Oral drug, per 60-days Oral drug, per 90-days | Q0521 | Supply Fee HIV PrEP FDA approved $24 (initial supply in a 30, 60, or 90-day period)$16 (additional supply in the same 30, 60, or 90-day period) | |
| Q0519 Q0520 | Injectable drug, per 30-days Injectable drug, per 60-days | |||
*Refer to PrEP for HIV & Related Preventative Services webpage under “How Do I Bill Starting January 1,2025?” for sample scenarios where billing for an additional supply fee would be appropriate
To complicate things even further, there were additional diagnosis codes approved (effective December 24, 2024) that are now accepted on Medicare Part B HIV PrEP claims which may not have been accepted previously. For more details, visit the CMS PrEP for HIV & Related Preventive Services webpage and click on the “What Diagnosis Code Can I Use?” heading.
Pharmacies that bill Medicare Part B must remain vigilant to ensure their claims will meet Medicare’s strict coverage requirements. An overview of DMEPOS claim guidance can be found within the 2024 PAAS National® DMEPOS Article Series. If you have any questions or concerns, or you have a Medicare Part B-related audit, contact PAAS!
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- 2025 PAAS Fraud, Waste & Abuse and HIPAA Compliance Program Updates - January 14, 2025
- CMS Updates HIV PrEP Supply Fee Code, Effective 01/01/2025 - January 6, 2025
- Medicare Part B Coverage of HIV PrEP - December 14, 2024
