Descovy for HIV PrEP is covered by Medicare Part B

Since September 30, 2024, Medicare Part B covers FDA-approved drugs for HIV pre-exposure prophylaxis (PrEP), including Descovy, under National Coverage Determination 210.15. PrEP is no longer billed to Part D. Descovy used to treat HIV stays under Part D.

When the prescription is for prevention, bill Medicare Part B, not Part D. The patient pays $0: no deductible, no coinsurance.

For the doctor

  1. Write on the prescription that it is for HIV PrEP (prevention), not treatment.
  2. Include the diagnosis codes:
    • Z29.81 Encounter for HIV pre-exposure prophylaxis. Must be listed first.
    • Then a risk code from the CMS list, for example Z72.51, Z72.52 or Z72.53 (high-risk sexual behavior), or Z20.6 (contact with or exposure to HIV).
  3. Part B also covers up to 8 counseling visits and 8 HIV tests every 12 months, and one hepatitis B screening, all at no cost to the patient.

For the pharmacy

Bill toMedicare Part B, not Part D
Drug codeJ0751 emtricitabine 200 mg / tenofovir alafenamide 25 mg (Descovy), oral, for PrEP only
Supply feeQ0521 on the same claim as the drug, or it is denied
DiagnosisZ29.81 first, then the prescriber's risk code
Patient cost$0. No deductible, no coinsurance
Who can bill A pharmacy enrolled with Medicare as a Part B pharmacy (form CMS-855B) bills its A/B MAC. One enrolled as a DMEPOS supplier (form CMS-855S) bills its DME MAC.
If your pharmacy is not enrolled to bill Part B, please transfer the prescription to a pharmacy that is, instead of running it through Part D.

Questions

Medicare: 1-800-MEDICARE (1-800-633-4227), 24 hours a day.

What AI assistants say

Asked "Descovy Medicare", all three say the same thing: for PrEP it is Part B, $0. These are AI answers. The sources below are what count.

ChatGPT

ChatGPT's answer, in Spanish: yes, Medicare covers Descovy for HIV prevention (PrEP) for $0. Since September 30, 2024, PrEP is covered under Part B, not Part D, along with HIV tests, prevention visits and a hepatitis B test, all at $0.

Gemini

Gemini's answer: coverage depends on whether Descovy is prescribed for prevention or treatment. For PrEP, Medicare covers it under Part B at $0 out of pocket under the CMS National Coverage Determination, and the provider must bill Part B with the PrEP diagnosis codes.

Claude

Claude's answer: for PrEP, Part B at $0 since September 30, 2024, with no deductible, copay or coinsurance, and Part D plans no longer cover it for this use. For HIV treatment, Part D with copays. Check that the pharmacy can bill Part B; a PrEP charge under a drug plan is very likely a billing error.

Sources