J0738Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)

Long descriptor

Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)

Short descriptor

Hiv prep, inj, lenacapavir

Code family

J — Drugs administered other than oral method; chemotherapy drugs

Status

Active

Added to HCPCS

Oct 1, 2025

Action effective date

Oct 1, 2025

Termination date

None

Medicare coverage code

D — Special coverage instructions apply

Pricing indicator

57 — Other carrier priced

NOC list

Not on the CMS NOC list

Maximum units per day (CMS Medically Unlikely Edits)

No published MUE for J0738. CMS keeps some MUE values confidential, so this does not mean there is no daily unit limit.

Quarterly history

Derived calculation “Derived $ / NDC” = billable units per NDC × the current payment limit. It is arithmetic for orientation, not a payment amount.

Drugs whose NDCs CMS crosswalks to J0738

• YeztugoLENACAPAVIR SODIUMDerived calculationDerived: 1 of 2 NDC package(s) for this drug appear in the CMS NDC–HCPCS crosswalk for J0738.

• Coverage documents for J0738 NCDs, LCDs, and Billing & Coding articles in the CMS Medicare Coverage Database that mention “J0738”. Covered diagnosis codes are listed in the articles.
• Self-administered drug (SAD) exclusion lists Drugs each MAC excludes from “incident to” Part B coverage because they are usually self-administered.
• Find your Medicare contractor (MAC) A/B and DME MAC jurisdictions by state — local coverage and prior-authorization rules come from your MAC.
• CMS discarded drug (JW/JZ) guidance When the JW and JZ modifiers are required for drugs from single-dose containers.
• NCCI Medically Unlikely Edits CMS MUE tables and quarterly changes for practitioner, outpatient hospital, and DME claims.

Verification neededCodeRx links to coverage documents instead of copying them: CMS distributes their code lists under AMA, ADA, and AHA license terms that limit reuse. Medicare Advantage, Medicaid, and commercial plans set their own coverage and prior-authorization rules.

All imported releases, checksums, and import reports are listed on the data sources page.

• A HCPCS code being valid does not mean Medicare or any other payer covers the item; coverage is determined by the payer and the MAC.
• CMS publishes NDC–HCPCS crosswalks to support ASP-based Part B payment; they are not a comprehensive list of NDCs that may be billed with this code.
• Payment limits are national Medicare Part B limits per billing unit, before deductible, coinsurance, and sequestration. They are not commercial payer rates.
• Hospital outpatient (OPPS) payment rates and status indicators are not included in this release.
• MUE values are the published CMS NCCI limits for Medicare fee-for-service claims; other payers may apply their own unit limits, and CMS keeps some MUE values confidential.