PrEP-AP Clinically Administered Medications

The California Department of Public Health, Office of AIDS (OA), PrEP Assistance Program (PrEP-AP) assists with medical out-of-pocket costs for clients for the PrEP-related services identified below. For reimbursement, all claims must include: 1) National Drug Codes (NDC) on claims for medication, 2) the corresponding Healthcare Common Procedure Coding System (HCPCS) codes or Current Procedural Terminology (CPT) code, and 3) the units administered for each code.

Please Note: Most contracted providers are required to be participants in the 340B Drug Pricing Program. All contracted providers are required to bill PAI at the discounted 340B rate if they wish to bill for clinically administered medications. Claims submitted in excess of this amount will only be paid up to the 340B amount. Uninsured clients, minor clients, and clients with confidentiality concerns must receive services at approved locations within the PrEP-AP Provider Network. Unless the client is a minor or is a client with confidentiality concerns, insured clients must receive services from a provider within their health plan network. PrEP-AP will pay for the actual portion of their co-payment obligation charged by the insurance plan.

Approved Clinically Administered Medications

Medications approved by PrEP-AP for direct dispense by a clinician are limited to single dose medications on the PrEP-AP Formulary. A prescription must be provided for all other medications on the PrEP-AP Formulary that require multiple doses or ongoing treatment. PrEP-AP will cover vaccination and therapeutic injection series that require more than a single dose of medication; however, each dose must be billed separately at the time of each individual injection administration.

The following are the only medications currently approved by PrEP-AP for administration in a clinical setting. A more detailed list of allowable permutations including NDCs and reimbursement amounts begins on page 5 of this document.

Billing for Administration

Billing for injection administration must be supported by corresponding CPT and/or HCPCS codes for the injections listed on the chart above. If more than one injection is administered, billing for administration must be displayed as separate line items.

The CPT codes below may be used when billing for injection administration:

Billing for Clinically Administered Medications

Approved medications that are administered in a clinical setting must be billed through the PrEP-AP’s Medical Benefits Manager, Pool Administrators Inc. (PAI) either electronically through the established medical claims clearinghouse or directly to PAI via a Centers for Medicare & Medicaid Services (CMS) Form 1500. As with all medical claims, PrEP-AP requires that claims be submitted within 180 days of the provider visit.

Reporting NDCs

NDCs are a universal product identifier for drugs by which drug products are identified and reported. NDCs consist of a unique, three-segment number with 11 digits in a 5-4-2 format. The first 5 digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The remaining digits are assigned by the manufacturer and identify the specific product and package size.

Some packages may display less than 11 digits, but leading zeroes can be assumed and must be used. Additionally, NDCs must be reported with hyphens displayed. 

For example: