Summary & Overview
HCPCS Q0516: Pharmacy Supplying Fee for HIV PrEP, 30-Day
HCPCS Level II code Q0516 denotes the pharmacy supplying fee for a 30-day supply of an FDA‑approved oral HIV pre‑exposure prophylaxis (PrEP) medication. Nationally, use of this code matters as payers and pharmacies align billing for medication supply and associated dispensing services distinct from the medication itself. Accurate reporting affects claims processing, benefit determination, and visibility into PrEP access across outpatient pharmacy settings.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a national perspective on coverage and billing considerations for PrEP dispensing fees and clarifies where this code fits in pharmacy service lines.
Readers will learn: the clinical and billing purpose of Q0516, typical sites of service and service type, common modifiers and operational considerations where available, and which payers are commonly involved in covering pharmacy supply fees. The summary also highlights where input data is limited: when specific associated taxonomies, ICD-10 diagnoses, related codes, or service-line details are not provided, the publication notes "Data not available in the input." The content is intended for billing managers, pharmacy operations leaders, and policy analysts seeking a concise, national-level reference for this HCPCS Level II code.
Billing Code Overview
HCPCS Level II code Q0516 represents a pharmacy supplying fee for HIV pre-exposure prophylaxis FDA-approved prescription oral drug, per 30-days. This code is used to report the service of dispensing or otherwise supplying a 30-day fill of an FDA-approved oral pre-exposure prophylaxis (PrEP) medication intended to reduce the risk of HIV acquisition.
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Service type: Pharmacy dispensing/supply of oral PrEP medication, per 30-day supply
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Typical site of service: Outpatient pharmacy or other ambulatory dispensing setting
Clinical & Coding Specifications
Clinical Context
A 28-year-old cisgender man with ongoing sexual exposure risk presents to a community health clinic for HIV prevention. The clinician prescribes an FDA-approved oral pre-exposure prophylaxis (PrEP) agent for HIV prevention with a 30-day supply. The clinic’s pharmacy dispenses the medication and bills the pharmacy-supplying fee using Q0516 for the 30-day supply. Typical workflow: patient assessment (risk history, HIV testing, renal function assessment), counseling on adherence and side effects, prescription generation, pharmacy fulfillment and counseling at pickup, billing of the pharmacy supplying fee Q0516, and follow-up visits for HIV testing and renal monitoring at recommended intervals.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when additional pharmacy services require substantially greater resources than typical (rare for dispensing fees). |
23 | Unusual anesthesia |