HIV PrEP Preventive Health Service Coverage
Posted on November 1, 2023
Back in 2021, with the release of the Division of Insurance Bulletin 2021-09, Health New England aligned our systems to look for the appropriate service codes and diagnosis related to PrEP (Pre-exposure prophylaxis) and respond as preventative care.
Once again, with the release of the new ICD diagnosis code Z29.81, we have added it to our systems under the same grouping. Some of the groupings referenced include, but are not limited to:
- Preventive Counseling: 99401 – 99404, 99406-99408
- Evaluation and Management Services Related to HIV: 99211-99212
- Pregnancy Testing: 81025, 84703
- Kidney Function: 82565, 82570, 82575, 82610
In addition, the Health Care Reform Copay Waiver Request Form is available on Optum.com (OptumRx Prior Authorization- Lines of Business). For consideration of a $0 cost share for primary prevention, we recommend providers fill this form out. Optum, on behalf of Health New England, will use the PrEP criteria and review your request.
For more information, please do not hesitate to call your Provider Relations Representative at (800) 842-4464, extension 5000, or send an email to providerrelations@hne.com.
