Prior Authorization No Longer Required for Antiretroviral Prescription Medications

As of September 30, 2024, Healthfirst has removed prior authorization requirements from all antiretroviral medications prescribed for the treatment or prevention of Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) for all Healthfirst plans. Prior authorization requirements were also removed for Preexposure Prophylaxis (PrEP) using antiretroviral medications for HIV prevention.

This change was implemented in accordance with a New York State bill recently signed into law, as well as a National Coverage Determination released by the Centers for Medicare and Medicaid Services (CMS).

Billing Tips

To ensure appropriate reimbursement, providers should: 

• Include the appropriate ICD-10 code for all prescriptions
• Include the National Drug Code (NDC) information
• For HIV PrEP, the diagnosis code (Z29.81) should be in the primary position on the prescription to ensure that cost share is not applied to the claim for in-network providers

Additional Resources

Decision Memo - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection National Coverage Analysis

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1 (888) 801-1660, Monday to Friday, 8:30am–5:30pm

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, ("Healthfirst").

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