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Allowable Pre-Exposure Prophylaxis (PrEP) Related Medical Services

Effective February 1, 2020

​​The California Department of Public Health, Office of AIDS (OA), PrEP Assistance Program (PrEP-AP) provides assistance with medical out-of-pocket costs for clients for the PrEP-related services identified below. For reimbursement, all claims must include: 1) a CPT code indicating the procedure or counseling session received, and 2) the ICD-10 code(s) substantiating the reason for the provider visit as being PrEP-related.

Please Note: Reimbursement rates identified in the right column apply to rates paid to contracted providers in the PrEP-AP Provider Network to provide services to uninsured clients. Uninsured clients must receive services at approved locations within the PrEP-AP Provider Network. Clients with insurance will have the actual portion of their co-payment obligation charged by the insurance plan paid for by the PrEP-AP.

​CPT Codes
​Description
​CDPH Reimbursement Rate

Office Visit - Outpatient Services - Medication Administration​ ​ ​

​99201
NEW PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (10 MINUTES)
​$46.49
​99202
NEW PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (20 MINUTES)
​$77.48 
​99203
NEW PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (30 MINUTES)
$109.92​
​99204
​NEW PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (45 MINUTES) 
​$166.86​​
​99205
​NEW PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (60 MINUTES)
$209.75​
​99211
​ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (5 MINUTES)
$23.07​
​99212
ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (10 MINUTES) 
​$45.77​
​99213
​ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (15 MINUTES)
$75.32​
​99214
​ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (25 MINUTES)
$110.28​
​99215
​ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT SERVICE (40 MINUTES)
​$147.76
​90471
​IMMUNIZATION ADMINISTRATION
$16.94​
​96372
​THERAPEUTIC, PROPHYLACTIC, & DIAGNOSTIC INJECTIONS AND INFUSIONS
$16.94​
​99373
​THERAPEUTIC, PROPHYLACTIC, & DIAGNOSTIC INJECTIONS AND INFUSIONS
​$16.94

​HIV Testing ​

​86359
​CD4 CELL COUNT
​$41.92
​86689
HTLV/HIV CONFIRMATORY TEST 
​$21.51​
​86701
HIV-1 
$9.87​​
​86702
​HIV-2
​$15.02
​86703
HIV-1/HIV-2, TYPE DIFFERENTIATING ASSAY (BIO RAD GEENIUS) 
$15.23​​
87389​
​HIV-1/2 ANTIGEN AND ANTIBODIES, FOURTH GENERATION WITH REFLEXES
​$26.75
​87390
​HIV-1 AG, EIA
​$24.06
​87391
​HIV-2 AG, EIA
​$21.90
​87534
​HIV-1, DNA, DIR PROBE
$22.28​
​87535
​HIV-1, RNA, QUALITATIVE, PCR
$38.99​
​87536
​HIV-1, VIRAL LOAD (RNA, QUANT)
$94.55​
​87537
​HIV-2, DNA, DIR PROBE
​$22.28
​87538
​HIV-2, DNA, AMP PROBE
​$38.99
​87539
​HIV-2, DNA, QUANT
$58.62​
​87900
​HIV-1 DRUG RESISTANCE ASSAY – PHENOTYPE PREDICTION USING GENOTYPIC BIOINFORMATICS
$144.83​
​87901
HIV-1 DRUG RESISTANCE ASSAY – PROTEASE AND REVERSE TRANSCRIPTASE GENOTYPE 
​$286.05​
​87906
​HIV-1 DRUG RESISTANCE ASSAY – INTEGRASE GENOTYPE
​$143.03

​STI Testing ​

​86592
​BLOOD SEROLOGY, QUALITATIVE
$4.75​
​86593
​BLOOD SEROLOGY, QUANTITATIVE
​$4.89
​86780
​TREPONEMA PALLIDUM PARTICLE AGGLUTINATION ASSAY
​$14.71
​87070
​CULTURE, BACTERIA, OTHER
$9.57​
​87081
​CULTURE
$7.36​
​87110
​CHLAMYDIA, CULTURE
$21.77​
​87164
DARK FIELD WITHOUT SPECIMEN COLLECTION 
​$11.93​
​87166
​DARK FIELD WITH SPECIMEN COLLECTION
​$12.56
​87205
SMEAR, GRAM STAIN 
$4.75​​
​87270
CHLAMYDIA TRACHOMATIS AG, IF 
​$13.32​
​87825
​TREPONEM PALLIDUM AG, IF
​$13.32
​87320
​CHLAMYDIA TRACHOMATIS AG, EIA
​$15.00
87490​
​CHLAMYDIA TRACH, DNA, DIR PROBE
​$22.75
​87491
​CHLAMYDIA TRACH, DNA, AMP PROBE
​$38.99
​87492
​CHLAMYDIA DNA OR RNA, QUANT
​$53.47
​87590
​N. GONORRHOEAE, DNA, DIR PROBE
​$26.88
​87591
​N. GONORRHOEAE, DNA, AMP PROBE
$38.99​
​87592
​N. GONORRHOEAE, DNA, QUANT
$47.60​
​87800
​SMEAR, GRAM STAIN
​$44.57
​87801
​MULTIPLE ORGANISM NAAT
​$77.99

Pregnancy Testing ​​

​81205
​HCG, QUALITATIVE, URINE
​$8.61

​Renal Function Testing​ ​

​80053
​COMPREHENSIVE METABOLIC PANEL
​$11.74
​82565
​CREATININE, BLOOD 
$5.69​

​Hepatitis A Screening​ 

​86708
​HAV AB
​$13.76

​Hepatitis B Screening​ ​

​80074
​ACUTE HEPATITIS PANEL
$52.93​
​87340
​HEPATITIS B SURFACE AG, EIA
​$11.48
​87341
​HEPATITIS B SURFACE AG, EIA
​$11.48
​86704
​HBV CORE AB
$13.39​
​86706
​HBV SURFACE AB  
​$11.93

​Hepatitis C Screening ​

​86803
​HEPATITIS C AB TEST
​$15.85
​86804
​HEPATITIS C AB TEST, CONFIRM
​$17.21

PrEP-Related ICD-10 Codes

​ICD-10 Code
​Description
​Z72.5
​HIGH-RISK SEXUAL BEHAVIOR
​Z72.51
​HIGH-RISK HETEROSEXUAL BEHAVIOR
​Z72.52
​HIGH-RISK HOMOSEXUAL BEHAVIOR
​Z72.53
​HIGH-RISK BISEXUAL BEHAVIOR
​Z20
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO COMMUNICABLE DISEASES
​Z20.2
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO INFECTIONS WITH A PREDOMINANTLY SEXUAL MODE OF TRANSMISSION
​Z20.5
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO VIRAL HEPATITIS
​Z20.6
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO HUMAN IMMUNODEFICIENCY VIRUS (HIV)
​Z20.8
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER COMMUNICABLE DISEASES
Z20.82​
CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER VIRAL COMMUNICABLE DISEASES​
​Z20.81
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER BACTERIAL COMMUNICABLE DISEASES
​Z20.9
​CONTACT WITH AND (SUSPECTED) EXPOSURE TO UNSPECIFIED COMMUNICABLE DISEASES
​Z29.8
​OTHER SPECIFIED PROPHYLACTIC MEASURES
​Z771.21
CONTACT WITH AND (SUSPECTED) EXPOSURE TO POTENTIALLY HAZARDOUS BODY FLUIDS​
​W46.0XXA
​CONTACT WITH HYPODERMIC NEEDLE (INITIAL ENCOUNTER)
​​W46.0XXD
​CONTACT WITH HYPODERMIC NEEDLE (SUBSEQUENT ENCOUNTER)
​​W46.1XXA
​CONTACT WITH CONTAMINATED HYPODERMIC NEEDLE (INITIAL ENCOUNTER)
​​W46.0XXD
CONTACT WITH CONTAMINATED HYPODERMIC NEEDLE (SUBSEQUENT ENCOUNTER)
​Z11.59 
ENCOUNTER FOR OTHER VIRAL DISEASES
​Z70.0
COUNSELING RELATED TO SEXUAL ATTITUDE
​Z70.1 
COUNSELING RELATED TO PATIENTS SEXUAL BEHAVIOR AND ORIENTATION
​Z11.4
​ENCOUNTER FOR SCREENING FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV)
​Z11.3
​ENCOUNTER FOR SCREENING FOR INFECTIONS WITH A PREDOMINANTLY SEXUAL MODE OF TRANSMISSION

​Physician Administered Medications

Please reference the PrEP-AP policy document linked here (https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/PrEP-AP%20Provider_Policy_Memo_2018-01.pdf)​


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