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25-915 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)
Act
immediately
Effective date
Not stated in the notice
Identified
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.
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What to do
immediately · 4 steps
01Billing team must update coding protocols for HIV PrEP services to use Z29.81 as primary diagnosis code for all PrEP-related encounters.
02Create billing guidelines distinguishing between daily oral PrEP and long-acting injectable PrEP frequency requirements.
03Train staff on proper CPT code selection based on patient demographics and risk categories.
04Verify billing system removes prior authorization requirements for FDA-approved PrEP medications unless therapeutic equivalents exist.
Codes mentioned
Z29.81994019940299403994049941199412993849938599386993879939499395993969939786689867018670286703873898739087391875348753587536878068670486705867068734087341874679074390746904719047286803868048256582570825758759087591875928785086631866328711087270873208749087491878108659286593867808006181025847028470380081G0432G0433G0435G0475G0011G0012G0013J0750J0751J0799J073996372
Original notice
25-915 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
See all Health Net changes →25-913 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)MediumNo effective date · Prior Authorization25-914 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)MediumNo effective date · Prior Authorization22-653 Stay Up to Date with Claims Edits for National Coverage Determination CodingHighEffective Oct 26, 2022 · Prior Authorization24-433 New Claims Edit for Non-Covered Lab ServicesHighEffective Jul 12, 2024 · ReimbursementBrowse every Health Net change in the policy list
Related policy hubs
Health Net policiesCA policy changesFamily MedicineInternal MedicineInfectious DiseaseOB-GYNCode Z29.81Code 99401Code 99402Code 99403Code 99404Code 99411Code 99412Code 99384Code 99385Code 99386Code 99387Code 99394Code 99395Code 99396Code 99397Code 86689Code 86701Code 86702Code 86703Code 87389Code 87390Code 87391Code 87534Code 87535Code 87536Code 87806Code 86704Code 86705Code 86706Code 87340Code 87341Code 87467Code 90743Code 90746Code 90471Code 90472Code 86803Code 86804Code 82565Code 82570Code 82575Code 87590Code 87591Code 87592Code 87850Code 86631Code 86632Code 87110Code 87270Code 87320Code 87490Code 87491Code 87810Code 86592Code 86593Code 86780Code 80061Code 81025Code 84702Code 84703Code 80081Code G0432Code G0433Code G0435Code G0475Code G0011Code G0012Code G0013Code J0750Code J0751Code J0799Code J0739Code 96372