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    v1.0.30
    OpenPayerPolicy UpdatesInfectious DiseasePremera HIV Medication Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedPremera Blue Cross of WashingtonPolicy N/A

    HIV/AIDS Pharmacologic Prevention and Treatment

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    Coverage criteria for brand-name HIV medications, specifically Truvada, for HIV pre-exposure prophylaxis or treatment under the pharmacy benefit.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyHIV/AIDS Pharmacologic Prevention and Treatment
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewSep 8, 2026
    Next Review DateN/A
    Key ActionDocument prior use of generic emtricitabine and tenofovir disoproxil fumarate with inadequate response or intolerance before requesting Truvada coverage.
    SourceLink
    POLICY UPDATE CHANGES

    The 2026 update removed coverage criteria for Apretude, Descovy, Rukobia, Sunlenca, Trogarzo, and Yeztugo.

    The 2026 update removed HCPCS codes J0738, J0739, J0750, J0751, J0752, J0799, J1746, and J1961.

    Coverage criteria were removed for Apretude, Descovy, Rukobia, Sunlenca, Trogarzo, and Yeztugo.

    HCPCS codes J0738, J0739, J0750, J0751, J0752, J0799, J1746, and J1961 were removed.

    1Active drug with medical-necessity criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Up to 3 years
    Maximum initial approval period
    Up to 3 yearsMaximum reauthorization period
    6HIV/AIDS products with coverage criteria removed
    8HCPCS codes removed
    Medicare Advantage excludedLine of business limitation

    Medical Necessity and Coverage Criteria

    Truvada (emtricitabine and tenofovir disoproxil fumarate)

    Truvada may be considered medically necessary when the following criterion is met:

    Truvada medical necessity: The individual has tried and had an inadequate response or intolerance to generic emtricitabine and tenofovir disoproxil fumarate.

    Investigational uses

    All other uses of the drugs listed in this policy are considered investigational.

    Investigational uses: The medication is used for a condition or indication not outlined in this policy.

    The medications are subject to the product's U.S. Food and Drug Administration dosage and administration prescribing information.

    Uses of medications listed in this policy for conditions or indications not outlined in the policy are excluded from coverage as investigational. The medications remain subject to the product’s FDA dosage and administration prescribing information.

    This medical policy does not apply to Medicare Advantage. Coverage is subject to the limits and conditions of the applicable member benefit plan.

    Historical and Removed HCPCS Codes

    Historical and removed HCPCS codesHCPCS
    J3490Historical HCPCS code referenced in policy history; later removed
    J3590Historical HCPCS code referenced in policy history; later removed
    J1746Historical HCPCS code referenced in policy history; later removed
    J0739Historical HCPCS code referenced in policy history; later removed
    J1961Historical HCPCS code referenced in policy history; later removed
    J0750Historical HCPCS code referenced in policy history; later removed
    J0751Historical HCPCS code referenced in policy history; later removed
    J0799Historical HCPCS code referenced in policy history; later removed
    J0752Historical HCPCS code referenced in policy history; later removed
    J0759HCPCS code added in the 2025 policy history
    1–10 of 11
    1/2
    Historical HCPCS codes addedHCPCS
    J3490HCPCS code added historically
    J3590HCPCS code added historically
    J1746New HCPCS code effective historically
    Historical HCPCS codes removedHCPCS
    J1961New HCPCS code added in a historical coding update
    J0750New HCPCS code added in a historical coding update
    J0751New HCPCS code added in a historical coding update
    J0799New HCPCS code added in a historical coding update
    J3490HCPCS code removed historically
    J0738HCPCS code removed in the latest coding update
    J0739HCPCS code removed in the latest coding update
    J0750HCPCS code removed in the latest coding update
    J0751HCPCS code removed in the latest coding update
    J0752HCPCS code removed in the latest coding update
    1–10 of 13
    1/2

    Submission and Reauthorization Requirements

    Prior Authorization

    Try generic therapy first

    Before Truvada can be considered medically necessary, the individual must have tried generic emtricitabine and tenofovir disoproxil fumarate and experienced an inadequate response or intolerance.

    Step Therapy

    Document the generic prerequisite

    Truvada requires prior use of generic emtricitabine and tenofovir disoproxil fumarate. Document the individual’s inadequate response or intolerance to the generic product.

    Documentation Required

    Include complete office documentation

    HIV Disease Background

    HIV is a chronic infection that primarily targets and progressively depletes CD4+ T-cell lymphocytes, weakening the immune system. As immune function declines, HIV can progress to acquired immunodeficiency syndrome (AIDS), which is associated with opportunistic infections and malignancies. Antiretroviral therapy suppresses viral replication, supports immune recovery, and helps reduce HIV-related morbidity and mortality.

    Key Terms

    Pre-exposure prophylaxis (PrEP)
    DefinitionPre-exposure prophylaxis (PrEP) is the use of FDA-approved medication by individuals without HIV to significantly reduce the chance of acquiring HIV.
    PopulationIndividuals without HIV.
    PurposeReduce the chance of acquiring HIV when the medication is taken as prescribed.
    AIDS
    CD4+ T-cell thresholdA CD4+ T-cell count below 200 cells/mm³.
    AIDS-defining illnessThe presence of an AIDS-defining illness also meets the definition of AIDS.
    Clinical context
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyHIV/AIDS Pharmacologic Prevention and Treatment
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewSep 8, 2026
    Next Review DateN/A
    Key ActionDocument prior use of generic emtricitabine and tenofovir disoproxil fumarate with inadequate response or intolerance before requesting Truvada coverage.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaHistorical and Removed HCPCS CodesSubmission and Reauthorization RequirementsHIV Disease BackgroundKey Terms

    Submit office visit notes documenting the diagnosis, relevant history, physical evaluation, medication history, and that medical-necessity criteria are met.

    • Diagnosis
    • Relevant history
    • Physical evaluation
    • Medication history
    • Documentation that medical-necessity criteria are met
    Documentation Required

    Document continued clinical response

    For reauthorization, chart notes must demonstrate that the individual continues to show a positive clinical response to Truvada therapy.

    Denial Risk

    Generic prerequisite not met

    Truvada may be denied when the individual has not tried generic emtricitabine and tenofovir disoproxil fumarate or has not demonstrated an inadequate response or intolerance to the generic product.

    Denial Risk

    Non-outlined uses may be denied

    Uses of medications listed in the policy for conditions not outlined in the policy are considered investigational and may be denied. The medications are subject to the product’s FDA dosage and administration prescribing information.

    Denial Risk

    Document response for reauthorization

    Reauthorization may be denied if medical-necessity criteria are not met or chart notes do not demonstrate continued positive clinical response to therapy.

    HIV progressively depletes CD4+ T-cell lymphocytes, impairing immune responses and increasing susceptibility to opportunistic infections and certain malignancies.
    Undetectable equals untransmittable (U=U)
    MeaningU=U means undetectable equals untransmittable.
    How it is achievedEffective antiretroviral therapy suppresses HIV replication to undetectable levels.
    Transmission relationshipWhen viral replication is suppressed to undetectable levels, sexual transmission of HIV is prevented.