Overview
The purpose of this management memorandum is to notify PrEP-AP Clinical Providers and Enrollment Workers of the approach for the coverage of Yeztugo for PrEP-AP clients.
PrEP-AP Coverage of Yeztugo
Effective October 20, 2025, The long-acting injectable PrEP Lenacapavir (Yeztugo) 927 mg by subcutaneous injection (2 x 1.5-mL injections) and 600 mg orally (2 x 300-mg tablets), has been added to the PrEP-AP Formulary for PrEP-AP clients with confidentiality concerns that prevent them from using insurance they have through a parent, guardian, spouse, or registered domestic partner, minors (ages 12-17) and uninsured clients that do not qualify for Pharmaceutical Assistance Programs (PAP) because their income is between 500-600% of the Federal Poverty Level (FPL). PrEP-AP Clinical Providers must complete and submit a PrEP-AP Long-acting Injectable PrEP Request Form before ordering medications for these clients.
Additionally, PrEP-AP clients with insurance, including Medicare or Medicare Advantage Plans can receive wrap-around coverage for Yeztugo after they have exhausted coverage available from insurance and the PAP.
Gilead, the manufacturers of Yeztugo, supports two programs, Gilead Advancing Access Pharmaceutical Assistance Program and the Gilead Co-pay Savings Program which can be utilized by both PrEP-AP uninsured and insured clients.
PrEP-AP Coverage of Yeztugo by Client Type
The PrEP-AP Long-Acting Injectable PrEP Coverage Flowchart provides a graphic representation of the information detailed below.
Clients will receive PrEP-AP benefits as described below:
Uninsured Clients
Uninsured PrEP-AP clients prescribed Yeztugo must enroll in the Gilead Advancing Access Pharmaceutical Assistance Program to access medications. Gilead will coordinate with a specialty pharmacy to mail the medication directly to the provider’s office for administration to the client.*
Insured Clients
Yeztugo should be fully covered by most comprehensive healthcare insurance plans as a preventative service. Yeztugo coverage may be a pharmacy benefit or a medical benefit depending on the plan.**
If the client’s health plan partially covers Yeztugo while imposing cost sharing, the client must apply to the Gilead Co-Pay Savings Program to cover up to $8000 annually for Yeztugo co-pays and deductibles, including up to $100 per visit for injection administration per treatment with no monthly limit. PrEP-AP will cover the remaining cost of Yeztugo if the Gilead Co-Pay Savings Program benefit is exhausted.
If the client’s health plan does not cover Yeztugo*** they are eligible to enroll in the Gilead Advancing Access Pharmaceutical Assistance Program for assistance with the full cost of medications.
*Uninsured Clients between 500-600% FPL do not qualify for Gilead PAP and are not required to apply.
**For more information on acquiring Yeztugo for insured clients, see the Gilead Yeztugo Coverage and Resources Page or download the Acquisition Guide.
***The client must have a private insurance plan with generic-only coverage, outpatient use only, or therapeutic class exclusion (non-coverage) of drug to be eligible for Gilead’s Patient Assistance Program.
Clients with Confidentiality Concerns & Minor Clients
PrEP-AP will cover the full cost of Yeztugo for clients who are enrolled in PrEP-AP as 1) clients with confidentiality concerns that prevent them from using health insurance they have through a parent, guardian, spouse, or domestic partner, 2) minor clients (ages 12-17) and 3) clients between 500-600% FPL who do not qualify for the Gilead PAP. The PrEP-AP Clinical Provider prescribing Yeztugo must fill out the PrEP-AP Long-acting Injectable Request Form attached to this memorandum, and available on the Prime Therapeutics website. This form must be completed and returned to Prime Therapeutics by fax at 1-800-424-5927 before the medication can be ordered.
PrEP-AP covers Yeztugo as a pharmacy benefit not a medical benefit. Prescriptions for Yeztugo must be filled through a pharmacy in the Prime Therapeutics pharmacy network and given to the provider for administration to the client. This may require special coordination with an onsite or local pharmacy. Alternatively, the prescription can be filled through a pharmacy in both the Advancing Access pharmacy network and the Prime Therapeutics pharmacy network – the pharmacy can mail the medication directly to the provider’s office for administration to the client.
Medicare Clients
Yeztugo should be fully covered by Medicare, but in the case it is not, PrEP-AP will cover the cost of Yeztugo co-pays for clients with Medicare or Medicare Advantage Plans if there are any.
The prescription can be filled through a pharmacy in both the client’s Medicare plan network and the Prime Therapeutics pharmacy network and provided directly to the provider’s office for administration to the client.
PrEP-AP Long-acting Injectable Request Form
The PrEP-AP Long-acting Injectable Request Form must be completed and submitted to Prime Therapeutics by fax at 1-800-424-5927 for eligible PrEP-AP client types. Once this form has been submitted to Prime Therapeutics and processed, the medication will be covered for the client. The form collects information on prior PrEP use and reason for long-acting injectable preference.
PrEP-AP Coverage of Related Medical Services
The PrEP-AP Allowable PrEP Related Medical Services page lists medical services covered under PrEP-AP. It includes allowable CPT and HCPCS codes for medical services that are necessary for the provision of Yeztugo, such as office visits, laboratory tests, and injection administration.
PrEP-AP Formulary
If you have any questions regarding the addition of this medication to the PrEP-AP formulary, please contact PrEP-AP Support at PrEP.Support@cdph.ca.gov.
Thank you,
Joseph Lagrama
ADAP Branch Chief
California Department of Public Health