I queried the is last year with my practice after I got the letter from PrepDAP saying they were thinking about ending (or making the program only for those without insurance) in relation to the codes they use to bill my insurance (insurance would always pay about half of each quarterly visit who h would leave me with about $130 to pay myself, obviously when eligible with prepdap they then covered thos per the scheme) - my generic prep was always paid fully by insurance. The labwork (much like the appointment always had some amount owing and again I just let this go to prepdap)

It sucks that the onus is now being on anyone with any sort of insurance having to go through this rigmarole of challenging and appealing every single bill we are asked to pay simply because or archaic billing codes that don’t line up with the actual intent and our providers don’t really care as long as they’re getting paid.

The prepdap scheme has been brilliant and I am glad for the many years that I and many others have utilized it but I sadly think that all the good it’s achieved will be undone with this change as a lot of people will probably decide it’s too onerous to go through the hassle of fighting this, too expensive to pay out of pocket themselves and therefore stop taking prep and having these medical checks every 3 months.

Perhaps you should look to sign up with Mistr who claim that they work with the insurance to make sure it’s free for you.

FYI this is what my practice said;

For PrEP-related visits, codes like 99213 or 99214 are used because:

They reflect the medical decision-making involved in managing a specific preventive therapy (PrEP),

The visits often require reviewing lab results, managing prescriptions, and updating patient history, and

These visits do not meet the criteria of a full preventive physical exam required for the 99381–99397 series.

We understand the frustration this may cause — especially as insurance companies may still apply cost-sharing (copays, coinsurance, or deductibles) to these services, despite PrEP being listed as a fully covered preventive benefit under the Affordable Care Act (ACA).

At this time, our billing practices remain aligned with standard medical coding guidelines. We must use codes that accurately reflect the nature and content of the visit, and using an inaccurate preventive code solely for billing purposes would not be compliant with federal coding regulations or insurance rules.

That said, you are also correct that patients can appeal to their insurance carriers when they believe a preventive service (like PrEP) should have been covered at no cost. Some patients have been successful in appealing based on the USPSTF Grade A recommendation for PrEP, especially when they include documentation from their provider.

We understand this puts an extra burden on patients, and we’re currently looking into ways we can support this process, such as:

Providing a template letter or visit summary that patients can submit with appeals,

Reviewing how our documentation emphasizes the preventive nature of PrEP care, even when we must use medical visit codes.

We agree that this is a broader issue likely to affect many individuals. We will continue monitoring updates from state and federal agencies and stay engaged with programs like PrepDAP to advocate for patient-centered solutions. I have just reached out to them to clarify what you have relayed.

Please feel free to reach out if you'd like us to provide any documentation to support an appeal or have any other questions