Policy & Billing
This page outlines the policy framework and payment pathways that support pharmacy-based PrEP and PEP services in California. It is intended to help pharmacies and referring clinicians understand the legal, operational, and financial context for participating in PrideScript.
California law authorizes pharmacists to provide preventive and clinical services, including initiating PrEP and PEP, ordering tests, and receiving reimbursement. The laws below form the foundation for pharmacy-based HIV prevention programs such as PrideScript.
A. Practice Authority
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Established the modern clinical role of pharmacists in California. It authorizes pharmacists to perform patient assessments, order and interpret tests, and independently furnish certain therapies, and it created the Advanced Practice Pharmacist pathway that supports expanded clinical care.
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Item descriptionAuthorizes trained pharmacists to independently initiate and furnish PrEP and PEP. It requires Medi-Cal to reimburse pharmacist-provided PrEP and PEP services and to reduce coverage barriers, such as prior authorization and step therapy.
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Expands pharmacist authority under SB 159 by allowing up to a 90-day supply of PrEP, aligning covered PrEP options with current CDC recommendations, and strengthening insurance coverage requirements for pharmacist-delivered PrEP and PEP.
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Requires health plans and certain insurers to reimburse pharmacists for covered clinical services within their scope of practice, including PrEP and PEP-related services, helping ensure pharmacists are paid for the care they provide.
Collaborative Practice Agreements (CPAs) are formal agreements between pharmacists and prescribers that allow pharmacists to provide expanded clinical services under shared protocols. In HIV, hepatitis C, STI, and substance use care, CPAs can support lab ordering and monitoring, ongoing therapy management, and follow-up coordination beyond initial service delivery. While California law already authorizes pharmacists to initiate services such as PrEP, PEP, HIV testing, and naloxone, CPAs help extend care, clarify clinical roles, and support continuity and reimbursement. PrideScript can assist pharmacies with CPA templates and implementation guidance.
CLIA-waived testing allows pharmacies to perform simple point-of-care tests on-site. These tests support same-day PrEP and PEP initiation and improve access to timely HIV prevention services. To offer CLIA-waived testing, a pharmacy must obtain a CLIA Certificate of Waiver from CMS, register as a clinical laboratory with the California Department of Public Health, pay modest federal and state fees, and comply with required testing, documentation, and public health reporting procedures. Pharmacies that meet these requirements may receive payment for CLIA-waived HIV testing in certain situations, including Medi-Cal fee-for-service when properly enrolled. Coverage varies across Medi-Cal managed care and commercial plans, and testing costs may be bundled with clinical services or funded through public health sources. PrideScript supports pharmacies with CLIA applications, workflow setup, and staff training.
B. Financial Sustainability
California policy supports pharmacy-based PrEP and PEP as financially viable services. Medication coverage, reimbursable clinical services, and robust patient assistance programs reduce the risk of uncompensated care. Pharmacy-based PrEP programs report high same-day initiation rates, with most patients who complete screening starting PrEP immediately. This supports efficient use of staff time and smooth integration into routine workflows. Demonstration projects in California and other states show that pharmacy-led PrEP services can be delivered sustainably while expanding access to prevention and clinical care.
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California law requires most private insurance plans to cover PrEP and PEP medications. Many plans now offer PrEP with zero cost sharing, so patients often pay nothing at the pharmacy counter. Multiple generic PrEP options are widely available, and California-based plans should not require prior authorization or step therapy for generic PrEP. Depending on the payer, pharmacies may bill for both medications and allowable clinical services related to PrEP and PEP initiation.
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Medi-Cal covers PrEP and PEP medications and supports pharmacist-provided services when billing criteria are met. For most Medi-Cal beneficiaries, PrEP and PEP are available at no cost. Medi-Cal also allows pharmacies to bill for certain clinical services, including HIV testing and PrEP-related care, making pharmacy-based prevention financially viable.
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Some insured patients may still have a pharmacy copay. National copay assistance programs can often reduce or eliminate out-of-pocket costs. The Patient Advocate Foundation supports patients with incomes below 400 percent of the federal poverty level, and the PAN Foundation supports patients with incomes below 500 percent. These programs can be used alongside private insurance to help ensure that PrEP and PEP remain affordable.
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For patients whose insurance does not fully cover medication or who do not qualify for copay programs, manufacturer assistance programs are available. Gilead, Merck, and ViiV Healthcare offer medication assistance for their PrEP and PEP products. These programs may provide medications at no cost to eligible patients, regardless of immigration status.
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Uninsured patients can still receive PrEP and PEP at no cost. In California, the PrEP Assistance Program (PrEP AP) is a key option for uninsured patients and often serves as the primary coverage pathway in pharmacy-based PrEP programs. PrEP AP can cover PrEP and PEP medications, as well as certain related services, for eligible patients. Additional options include the federal Ready, Set, PrEP program and manufacturer assistance programs.
Next Steps
The PrideScript team can help pharmacies and clinicians understand policy requirements, billing pathways, and setup considerations.