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​​Allowable AIDS Drug Assistance Program (ADAP) Related Medical Services-Cabenuva

Cabenuva (cabotegravir extended-release injectable suspension and rilpivirine extended-release injectable suspension co-packaged for intramuscular use) is the first long-acting injectable antiretroviral (ARV) medication approved by the U.S. Food and Drug Administration. Cabenuva is a complete regimen for the treatment of HIV-1 infection in adults who have achieved viral suppression on a stable oral antiretroviral regimen but want to switch to a monthly injectable regimen. The California Department of Public Health, Office of AIDS (OA), ADAP provides assistance with medical-out-pocket costs for clients who are prescribed Cabenuva. For reimbursement, all claims must include: 1) a Current Procedural Terminology (CPT) code indicating the procedure or counseling session received, and 2) the International Classification of Diseases (ICD)10 code(s) substantiating the reason for the provider visit as being related to Cabenuva, and 3) the National Drug Code (NDC) code describing the type of Cabenuva administered. 

Please Note: Reimbursement rates identified in the right column apply to rates paid to contracted providers in the Provider Network to provide services to uninsured ADAP clients. Uninsured ADAP clients can receive services at approved locations within the Provider Network. Clients with insurance will have to visit a provider within their insurance network and will need to seek reimbursement for the co-payment obligation by completing and submitting a Medical Out of Pocket Claim form (PDF).

*When a patient receives two injections – Cabenuva requires two IM (intramuscular) injections – some providers may include two-line items using CPT 96372 (with the second CPT 96372 containing a modifier) to note each injection as a distinct procedural service.

Office Visit - Outpatient Services - Medication Administration 

​CPT Code
​Description
​CDPH Reimbursement Rate
​96372
​THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION 
(SQ OR IM)
​$14.54
​99202
​OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, STRAIGHTFORWARD 15-29 MINUTES
​$74.06
​99203
​OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LOW 30-44 MINUTES
​$113.85
​99204
​OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, MODERATE 45-59 MINUTES 
$169.57​
​99211
​OFFICE OR OTHER OUTPATIENT VISIT, EXISTING PATIENT, MINIMAL PROBLEMS
​$23.53
​99212
​OFFICE OR OTHER OUTPATIENT VISIT, EXISTING PATIENT, STRAIGHTFORWARD 10-19 MINUTES
​$57.45
​99213
OFFICE OR OTHER OUTPATIENT VISIT, EXISTING PATIENT, LOW COMPLEXITY 20-29 MINUTES  
​$92.05

​99214

​OFFICE OR OTHER OUTPATIENT VISIT, EXISTING PATIENT, MODERATE 30-39 MINUTES

​$129.77

Cabenuva ICD-10 Codes

​ICD-10 Code
​Description
​B20
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
​Z21
ASYMPTOMATIC HIV INFECTION STATUS

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