Insurance and Paying for PrEP
PrEP is an important tool for preventing HIV. However, it’s fairly common to face issues getting insurance and prescription plans to pay for PrEP. Following is information about your insurance rights and expansive resources and tools for getting on PrEP and getting it paid for.
Do you know your PrEP insurance rights?
Did you know that most private health plans must cover PrEP at zero costs to you? In 2021, the US government issued guidelines that most private health plans and Medicaid expansion plans must cover PrEP, because the United States Preventive Services Task Force (USPSTF) gave PrEP a Grade A recommendation. For you, this means that you are required to pay ZERO co-pays, co-insurance, or deductibles for your:
- Medication,
- PrEP provider visits,
- Labs,
- HIV & STI screenings,
- Adherence counseling, and
- Pregnancy tests.
What resources do I need to get on PrEP and get it covered?
The resources below identify ways to pay for PrEP (including the requirement for zero-cost co-pays), resources to help consumers advocate for their rights, and billing guides for providers to ensure paperwork is coded correctly so insurance plans approve and cover PrEP costs. Additional information on patient assistance programs is available on the Covering the Costs of PrEP and PEP page.
Read about the USPSTF recommendations and learn how to advocate for yourself and your PrEP!
ICD-10-CM Codes (Outpatient and Clinical Billing Codes)
A list of all ICD-10-CM codes used in clinical and outpatient settings in the U.S.
Medical Coding Clinic, Clearinghouse, and Inquiries
A tool from Coding Clinic Advisor through which specific coding questions may be submitted.
State Level Department of Insurance Guide
Links to state-by-state Dept. of Insurance consumer complaint websites.
ICD-10 Code Lookup Tool
A quick lookup tool from the Centers for Medicare & Medicaid for finding billing codes pertinent to PrEP coverage.
USPSTF – PrEP FAQs
Frequently Asked Questions (FAQs) regarding implementation of PrEP from USPSTF.
ICD-10-PCS Codes (Inpatient and Hospital Billing Codes)
A list of all ICD-10-PCS codes used in inpatient and hospital settings in the U.S.
Covering Costs of PrEP Job Aid
Tips and Resources for Covering Costs of HIV PrEP from HealthHIV.
Know Your Rights Handout
A guide for what patients need to know about new Federal Guidelines on Coverage of PrEP with No Cost-Sharing
Billing Coding Guide for HIV Prevention: PrEP, Screening, and Linkage Services
A resource guide from NASTAD to assist in navigating billing and reimbursement for HIV prevention services.
Patient Advocacy Toolkit
A guide for patients to ensure plans comply with USPSTF patient protections for PrEP.