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PrEP for HIV: Billing for Yeztugo® (lenacapavir) for Pre-exposure Prophylaxis
Scheduled for Oct 1, 00:00 - 00:05 EDT
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This message is intended for MedRx customers.
CMS has published guidelines for a new HIV PrEP drug, Lenacapavir.
Beginning October 1st, 2025 this drug will be billable through Optum Insight Medicare MedRX.
Additional information including access to the ASP Drug Pricing Files can be viewed here: PrEP | CMS
How Do I Bill for Lenacapavir?
From June 18-September 30, 2025, use this code:
Code: J0799
Descriptor: FDA approved prescription drug, only for use as hiv pre-exposure prophylaxis, not otherwise classified
Payment Limit: Unless specified on the ASP Drug Pricing Files, the MACs determine pricing her 42 CFR 410.152(o)
Starting October 1, 2025, use these codes:
Code: J0738
Descriptor: Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)
Payment Limit: View ASP Drug Pricing Files for October 2025 and later
Code: J0752
Descriptor: Oral, lenacapavir, 300 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)
Payment Limit: View ASP Drug Pricing Files for October 2025 and later
CMS has published guidelines for a new HIV PrEP drug, Lenacapavir.
Beginning October 1st, 2025 this drug will be billable through Optum Insight Medicare MedRX.
Additional information including access to the ASP Drug Pricing Files can be viewed here: PrEP | CMS
How Do I Bill for Lenacapavir?
From June 18-September 30, 2025, use this code:
Code: J0799
Descriptor: FDA approved prescription drug, only for use as hiv pre-exposure prophylaxis, not otherwise classified
Payment Limit: Unless specified on the ASP Drug Pricing Files, the MACs determine pricing her 42 CFR 410.152(o)
Starting October 1, 2025, use these codes:
Code: J0738
Descriptor: Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)
Payment Limit: View ASP Drug Pricing Files for October 2025 and later
Code: J0752
Descriptor: Oral, lenacapavir, 300 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)
Payment Limit: View ASP Drug Pricing Files for October 2025 and later
This scheduled maintenance affects: Pharmacy Solutions (MedRx).