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Allowable Pre-Exposure Prophylaxis (PrEP) Related Medical Services

Effective March 18, 2024

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.

Office Visit ā€“ Outpatient Service ā€“ Medication Administration

CPT Codes Description CDPH Reimbursement Rate
99202 New Patient Office or Other Outpatient Service (20 minutes) $72.86
99203 New Patient Office or Other Outpatient Service (30 minutes) $112.84
99204 New Patient Office or Other Outpatient Service (45 minutes) $167.40
99205 New Patient Office or Other Outpatient Service (60 minutes) $220.95
99211 Established Patient Office or Other Outpatient Service (5 minutes) $23.38
99212 Established Patient Office or Other Outpatient Service (10 minutes) $56.93
99213 Established Patient Office or Other Outpatient Service (15 minutes) $90.82
99214 Established Patient Office or Other Outpatient Service (25 minutes) $128.43
99215 Established Patient Office or Other Outpatient Service (40 minutes) $179.94
90471 Immunization Administration $22.21
90472 Immunization Administration, Each Additional $15.92
90473 Immunization Administration, Intranasal or Oral $18.14
90474 Immunization Administration, Each Additional Intranasal or Oral $12.96
96372 Therapeutic, Prophylactic, & Diagnostic Injections and Infusions $14.23
96373 Therapeutic, Prophylactic, & Diagnostic Injections and Infusions $18.30
99421 Online Digital Evaluation and Management Service (5-10 minutes) $14.91
99422 Online Digital Evaluation and Management Service (11-20 minutes) $29.48
99423 Online Digital Evaluation and Management Service (21 or more minutes) $47.10
99441 Audio-only (Telephone) Evaluation and Management Service (5-10 minutes) $56.25
99442 Audio-only (Telephone) Evaluation and Management Service (11-20 minutes) $90.82
99443 Audio-only (Telephone) Evaluation and Management Service (21-30 minutes) $127.76
98970 Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (5-10 minutes) $11.52
98971 Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (11-20 minutes) $20.33
98972 Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (21-30 minutes) $31.18
G2012 Brief Communication Technology-based Service (5-10 minutes) $14.23
G2010 Remote Evaluation of Recorded Video and/or Images Submitted by an Established Patient $12.20
G2250 Remote Evaluation of Recorded Video and/or Images Submitted by an Established Patient $12.11
G2251 Brief Communication Technology-based Service (5-10 minutes) $14.23
G2252 Brief Communication Technology-based Service (11-20 minutes) $26.77

HIV Testing

CPT Codes Description CDPH Reimbursement Rate
85025 Complete Blood Cell Count (red cells, white blood cells, platelets), Automated $7.77
85026 Complete Blood Cell Count (red cells, white blood cells, platelets), Automated $7.77
85027 Complete Blood Cell Count (red cells, white blood cells, platelets), Automated $6.47
86359 CD4 Cell Count $37.73
86689 HTLV/HIV Confirmatory Test $19.35
86701 HIV-1 $8.89
86702 HIV-2 $13.52
86703 HIV-1/HIV-2, Type Differentiating  Assay (Bio Rad Geenius) $13.71
87389 HIV-1/2 Antigen and Antibodies, Fourth Generation with Reflexes $24.08
87390 HIV-1 AG, EIA $24.06
87391 HIV-2 AG, EIA $21.90
87534 HIV-1, DNA, DIR Probe $21.92
87535 HIV-1, RNA, Qualitative, PCR $35.09
87536 HIV-1, Viral Load (RNA, Quant) $85.10
87537 HIV-2, DNA, DIR Probe $21.92
87538 HIV-2, DNA, AMP Probe $35.09
87539 HIV-2, DNA, Quant $58.62
87806 HIV-1 Antigen and Antibodies, with HIV 1/2 Antibodies $32.77
87900 HIV-1 Drug Resistance Assay - Phenotype Prediction Using Genotype Bioinformatics $130.35
87901 HIV-1 Drug Resistance Assay - Protease and Reverse Transcriptase Genotype  $257.45
87906 HIV-1 Drug Resistance Assay - Integrase Genotype  $128.73
G0432 HIV-1/2 Antigen/Antibody, EIA $19.57
G0433 HIV-1/2 Antigen/Antibody, ELISA $18.29
G0435 HIV-1/2 Antigen/Antibody, Rapid Oral Fluid Test $11.98
G0475 HIV Antigen/Antibody, Combination Assay, Screening $24.08

STI Testing

CPT Code
 Description CDPH Reimbursement Rate
86592 Blood Serology, Qualitative (Including Non-Treponemal Syphilis Tests (RPR, VRDL) $4.27
86593 Blood Serology, Quantitative (Including RPR and VRDL Titers) $4.40
86780 Syphilis Immunoassays (Including T. Pallidum Antibody and the TPPA Assay) $13.24
87070 Culture, Bacteria, Other $8.62
87081 Culture $6.63
87110 Chlamydia, Culture $19.60
87164 Dark Field without Specimen Collection $10.74
87166 Dark Field with Specimen Collection $11.30
87205 Smear Gram Stain $4.27
87270 Chlamydia Trachomatis AG, IF $11.98
87285 Treponema Pallidum AG, IF $12.18
87320 Chlamydia Trachomatis AG, EIA $15.00
87490 Chlamydia Trach, DNA DIR Probe $22.75
87491 Chlamydia Trach, DNA AMP Probe $35.09
87492 Chlamydia DNA or RNA, Quant $53.47
87590 N. Gonorrhoeae, DNA, DIR Probe $26.88
87591 N. Gonorrhoeae, DNA, AMP Probe $35.09
87592 N. Gonorrhoeae, DNA, Quant $42.84
87593 Mpox (Orthopoxvirus), DNA, PCR $35.09
87800 Smear Gram Stain $43.67
87801 Multiple Organism NAAT $70.20

Pregnancy Testing

CPT Code
 Description CDPH Reimbursement Rate
81025 hCG, Qualitative, Urine $8.61
84702 hCG Beta Subunit, Total, Quantitative, Serum $15.05
84703 hCG Beta Subunit, Qualitative $7.52
84704 hCG Free Beta Chain Test $15.29

Renal Function Testing

CPT Code
 Description
 CDPH Reimbursement Rate
80053 Comprehensive Metabolic Panel $10.56
82565 Creatinine, Blood $5.12
82570 Creatinine, Blood $5.18
82575 Creatinine, Blood $9.46

Hepatitis A Screening

CPT Code
 Description
 CDPH Reimbursement Rate
86708 HAV AB $12.39

Hepatitis B Screening

CPT Code
 Description
 CDPH Reimbursement Rate
80074 Acute Hepatitis Panel $47.63
86705 Hepatitis B Core Antibody (IGM) Measurement $11.77
86706 HBV Surface AB $10.74
87340 Hepatitis B Surface AG, EIA $10.33
87341 Hepatitis B Surface AG, Immunoassay $10.33
87350 Detection Test by Immunoassay $11.53
86704 HBV Core AB $12.05
86704 Hepatitis B Core Antibody (HBcAb), Total $12.05
87467 Hepatitis B Surface Antigen (HBcAb), Quantitative $15.05
G0499 Hepatitis B Screening $28.27

Hepatitis C Screening

CPT Code
 Description
 CDPH Reimbursement Rate
86803 Hepatitis C AB Test $14.27
86804 Hepatitis C AB Test,  Confirm $15.49
87522 Hepatitis C Viral RNA, Quantitative, Real-Time PCR $42.84
G0472 Hepatitis C Screening $46.35

Liver Function Test

CPT Code
 Description
 CDPH Reimbursement Rate
84460 Transferase Alanine Amino ALT SGPT $5.30

Cholesterol and Triglyceride Screening

CPT Code
 Description
 CDPH Reimbursement Rate
80061 Lipid Panel $13.39
82465 Cholesterol, Total $4.35
83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) $8.19
83719 Lipoprotein, direct measurement; very low density cholesterol (VLDL cholesterol) $12.75
83721 Lipoprotein, direct measurement; low density cholesterol (LDL cholesterol) $10.50
84478 Triglycerides $5.74

Other

CPT Code
 Description
 CDPH Reimbursement Rate
36415 Collection Venous Blood Venipuncture $8.57
81001 Urinalysis; automated, with microscopy $3.17
87045 Infectious agent detection; gastrointestinal pathogen $9.44
87046 Stool Culture; additional pathogens $9.44
87086 Urine Culture; bacterial colony count $8.07
87177 Stool for ova and parasite smear $8.90
87269 Giardia; immunofluorescent $13.61
87329 Giardia; immunoassay $11.98
87427 Shiga-like toxin antigen; immunoassay $11.98
87449 Infectious Agent Antigen; immunoassay (can be used for Campylobacter antigen detection) $11.98
87480 Candida; direct probe $20.05
87505 Infectious agent detection; gastrointestinal pathogen $128.29
87506 Infectious agent detection; gastrointestinal pathogen $262.99
87507 Infectious agent detection; gastrointestinal pathogen $416.78
87510 Gardnerella Vaginalis; direct probe $20.05
87660 Trichomonas Vaginalis; direct probe $20.05

PrEP Related ICD-10 Codes

ICD-10 Codeā€‹
 Description
Z29.81 Encounter for HIV Pre-Exposure Prophylaxis
Z71.7 Encounter for HIV Counseling
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 Disease
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)
W46.1XXD 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
Z01.812 Encounter for Preprocedural Laboratory Examination
Z51.81  Encounter for Therapeutic Drug Level Monitoring
Z79.899 Other Long Term (Current) Drug Therapy
F11.10 Opioid Abuse, Uncomplicated
F11.20 Opioid Dependence, Uncomplicated
F11.21 Opioid Dependence in Remission
F11.90 Opioid Use, Uncomplicated
Z20.828 Contact with and Exposure to Other Viral Communicable Diseases
Z20.89 Contact with and (Suspected) Exposure to Other Viral Communicable Diseases
Z32.00 Encounter for Pregnancy Test Result Unknown
Z32.01 Encounter for Pregnancy Test Result Positive
Z32.02 Encounter for Pregnancy Test Result Negative
Z86.59 Personal History of Other Mental and Behavioral Disorders
Z87.898 Personal History of Other Specified Conditions

Clinically Administered Medications 
PrEP-AP Allowable Clinically Administered Medications



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