HIV Pre-Exposure Prophylaxis and Post-Exposure Prevention

Date: 02/02/18

A recent notification from DHCS to health plans detailed issues regarding treatment delay and denials of Pre-Exposure Prophylaxis (PrEP) and PEP (post-exposure prevention), medications used to prevent serocoversion to HIV.  This has the potential to negatively impact beneficiaries, as the consequences of delaying or denying access to these medications can be life-altering.

The DHCS would like MCOs (Managed Care Organizations) to remind and educate their respective network providers, network pharmacies, and staff about the scope of benefit and the proper submission of claims for these medications. These medications are considered a non-capitated, covered benefit and are billed through the Medi-Cal FFS system and not through the MCOs.

Please share this information with any providers, pharmacies, or staff that provide care for members that may be affected by this issue so that time sensitive treatment is not delayed.

Additional information and resources for consumers and providers regarding PrEP and PEP are available at: https://www.cdc.gov/hiv/risk/index.html