Summary & Overview
HCPCS J0751: Emtricitabine 200mg / Tenofovir Alafenamide 25mg for HIV PrEP
HCPCS Level II code J0751 identifies the oral combination product emtricitabine 200 mg with tenofovir alafenamide 25 mg when prescribed exclusively for HIV pre-exposure prophylaxis (PrEP). The code matters nationally as PrEP is a key preventive intervention in public health strategies to reduce HIV transmission; accurate coding affects coverage determinations, pharmacy claims adjudication, and access to medication.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The summary addresses how payers classify and reimburse this PrEP-specific antiviral within pharmacy and outpatient benefit structures.
Readers will find a concise overview of the code’s clinical context, typical settings where the product is dispensed, and the role of this HCPCS Level II code in billing workflows. The publication also outlines expected benchmark topics and policy considerations that stakeholders track nationally: coverage scope for PrEP, site-of-service categorization (outpatient pharmacy), and implications for claims processing and benefit design.
Data not available in the input includes specific payer coverage policies, reimbursement rates, associated taxonomies, ICD-10 diagnosis pairings, and related billing codes.
Billing Code Overview
HCPCS Level II code J0751 represents the oral combination medication emtricitabine 200 mg and tenofovir alafenamide 25 mg, FDA-approved only for use as HIV pre-exposure prophylaxis (PrEP) and not for treatment of HIV.
Service Type: Prescription medication for HIV pre-exposure prophylaxis (PrEP).
Typical Site of Service: Outpatient pharmacy dispensing or retail/mail-order pharmacy.
Clinical & Coding Specifications
Clinical Context
A sexually active adult with documented risk factors for HIV acquisition presents to an outpatient primary care clinic or sexual health clinic seeking HIV pre-exposure prophylaxis (PrEP). The patient is HIV-negative by fourth-generation antigen/antibody testing, has normal renal function (eGFR ≥ 60 mL/min/1.73m2), and no contraindicating comorbidities or drug interactions. A clinician (family medicine, infectious disease, or sexual health specialist) performs baseline evaluation including HIV testing, hepatitis B status, renal function, pregnancy test if applicable, and counseling on adherence and risk-reduction. After confirmation of eligibility, a prescription for the single-tablet formulation containing emtricitabine 200 mg and tenofovir alafenamide 25 mg is dispensed for daily oral use as HIV pre-exposure prophylaxis (J0751). Follow-up visits are scheduled at 1 month after initiation and every 3 months thereafter for repeat HIV testing, assessment of adherence and side effects, renal monitoring, and sexual health screening. Typical sites of service include outpatient primary care clinics, sexual health clinics, community health centers, and specialty infectious disease or HIV prevention clinics. Pharmacy dispensing and outpatient infusion centers are not typical sites because the medication is oral and dispensed through pharmacies.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier |