HCA establishes payment for Medicaid HIV antiviral drugs dispensed in emergency department    

The Health Care Authority (HCA) has completed an update to its  Prescription Drug Program Billing Guide billing guide. Hospital emergency departments (EDs) may now bill for up to a 28-day supply of HIV postexposure prophylaxis (PEP) drugs or drug therapies dispensed to a Medicaid Fee- For-Service or Medicaid managed care client following possible exposure to HIV, unless the treatment is medically contraindicated, inconsistent with accepted standards of care or inconsistent with CDC guidelines.  

Payment is retroactive to Jan. 1, 2025. Emergency Departments must bill for take-home HIV PEP drugs or drug therapies as a separate line item with HCPCS code J8499 and the National Drug Code (NDC) for the products that were dispensed. The take-home HIV PEP is reimbursed separately from the bundled ED rate. For more information, see page 74 of the Prescription Drug Billing Guide and our previous bulletin.   

ESSB 6127 took effect on Jan. 1, 2025. When originally introduced, the bill required hospitals to provide 28-days’ worth of HIV PEP drugs or therapies to ED patients with suspected HIV exposure but didn’t properly amend dispensing laws, allow for flexibility or provide for hospital reimbursement. WSHA engaged in the bill to resolve statutory conflicts and ensure a payment mechanism.  

Please let WSHA know if you experience difficulties obtaining payment for HIV PEP drugs provided after Jan. 1, 2025 from either HCA or the Medicaid managed care plans. (Katerina LaMarche)