Form CDPH8741 "The Provider Referral Form for Insured Clients - Pre-exposure Prophylaxis Assistance Program (Prep-Ap)" - California

What Is Form CDPH8741?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8741 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8741 "The Provider Referral Form for Insured Clients - Pre-exposure Prophylaxis Assistance Program (Prep-Ap)" - California

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State of California-Health and Human Services Agency
California Department of Public Health
The Provider Referral Form for Insured Clients
Pre-Exposure Prophylaxis Assistance Program (PrEP-AP)
The client below is newly enrolled in the PrEP-AP administered by the California Department of Public
Health (CDPH). The client may be eligible to receive assistance from CDPH for PrEP-related medical
out-of-pocket costs, including deductibles, coinsurance, and medical copayments. You are being
provided this referral form to communicate the CDPH PrEP-AP as a possible secondary payer source
after the client’s primary insurance coverage. Providers must verify client eligibility in PrEP-AP
prior to rendering services. Client eligibility can be verified by calling CDPH at 1-844-421-7050.
Please fill out the Clinical Provider Section of this form and fax the completed form to the client’s
enrollment worker at the number below.
Allowable PrEP-related services are limited to very specific medical billing codes that include
assistance toward clinical assessments for PrEP eligibility as an HIV prevention measure and on-going
monitoring and evaluation as recommended by the Centers for Disease Control and Prevention Clinical
Practice Guidelines for PrEP. Please visit
www.cdph.ca.gov/PrEP-AP/Resources
for a comprehensive
list of allowable ICD-10 codes and medical billing codes. All claims must also include an ICD-10 code(s)
substantiating the provider visit as being PrEP-related.
Please do not charge the client a copay for PrEP-related services for any reason. To receive
payment for allowable PrEP-related services, please bill the PrEP-AP’s Medical Benefits Manager, Pool
Administrators, Inc. (PAI) and provide supporting documentation using one of the methods indicated
below. PAI will remit payment within 60 days of receiving a valid claim.
1. Electronically: Payer ID: PAI02
2. Mail: PAI-CDPH - 02, 628 Hebron Avenue, Suite 502, Glastonbury, CT 06033
3. Fax: 860-724-4599
4. Email Address: CDPHPrEP@pooladmin.com
Enrollment Worker complete the following:
Check here if the client is already enrolled in the Gilead Patient Assistance Program and does not require a
clinical assessment to be prescribed PrEP
Client Name:
PrEP-AP ID Number:
Enrollment Worker Name:
Phone:
Email:
Fax:
Name and address of agency client was referred to:
CDPH 8741 (4/20)
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State of California-Health and Human Services Agency
California Department of Public Health
The Provider Referral Form for Insured Clients
Pre-Exposure Prophylaxis Assistance Program (PrEP-AP)
The client below is newly enrolled in the PrEP-AP administered by the California Department of Public
Health (CDPH). The client may be eligible to receive assistance from CDPH for PrEP-related medical
out-of-pocket costs, including deductibles, coinsurance, and medical copayments. You are being
provided this referral form to communicate the CDPH PrEP-AP as a possible secondary payer source
after the client’s primary insurance coverage. Providers must verify client eligibility in PrEP-AP
prior to rendering services. Client eligibility can be verified by calling CDPH at 1-844-421-7050.
Please fill out the Clinical Provider Section of this form and fax the completed form to the client’s
enrollment worker at the number below.
Allowable PrEP-related services are limited to very specific medical billing codes that include
assistance toward clinical assessments for PrEP eligibility as an HIV prevention measure and on-going
monitoring and evaluation as recommended by the Centers for Disease Control and Prevention Clinical
Practice Guidelines for PrEP. Please visit
www.cdph.ca.gov/PrEP-AP/Resources
for a comprehensive
list of allowable ICD-10 codes and medical billing codes. All claims must also include an ICD-10 code(s)
substantiating the provider visit as being PrEP-related.
Please do not charge the client a copay for PrEP-related services for any reason. To receive
payment for allowable PrEP-related services, please bill the PrEP-AP’s Medical Benefits Manager, Pool
Administrators, Inc. (PAI) and provide supporting documentation using one of the methods indicated
below. PAI will remit payment within 60 days of receiving a valid claim.
1. Electronically: Payer ID: PAI02
2. Mail: PAI-CDPH - 02, 628 Hebron Avenue, Suite 502, Glastonbury, CT 06033
3. Fax: 860-724-4599
4. Email Address: CDPHPrEP@pooladmin.com
Enrollment Worker complete the following:
Check here if the client is already enrolled in the Gilead Patient Assistance Program and does not require a
clinical assessment to be prescribed PrEP
Client Name:
PrEP-AP ID Number:
Enrollment Worker Name:
Phone:
Email:
Fax:
Name and address of agency client was referred to:
CDPH 8741 (4/20)
1 of 2
Contracted PrEP-AP Provider complete the following:
Provider Name:
NPI Number:
Client is HIV negative and clinically eligible for PrEP and will be prescribed
Truvada®
Descovy®
For HIV negative clients only, please fax this form and the completed Gilead application to the enrollment worker
identified above.
Client is HIV positive and not eligible for PrEP (complete the following steps)
1. Please initiate rapid antiretroviral therapy in accordance with the policy outlined in
PrEP-AP Provider Network Policy
Seroconversion, or refer client to a clinical care provider
Document 2019-02: Initiation of Rapid Antiretroviral Therapy Due to
ideally with a same day appointment
2. Indicate here which rapid antiretroviral regimen will be used, if applicable:
Bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy®)
fixed dose combination 1 tablet once daily - Preferred regimen
Dolutegravir (Tivicay®) 50 mg once daily + tenofovir alafenamide/emtricitabine (Descovy®)
1 tablet once daily - Preferred regimen
Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (Symtuza®)
fixed dose combination 1 tablet once daily
Raltegravir (Isentress® HD) 1200 mg (two pills) once daily + tenofovir alafenamide/emtricitabine
(Descovy®) 1 tablet once daily (raltegravir can also be dosed 400mg twice daily)
Other (Please specify regimen including dose): _________________________________________
3. Provide the client with this form and a completed
to facilitate the client’s enrollment into the
Diagnosis Form
AIDS Drug Assistance Program (ADAP)
4. Refer the client to an ADAP enrollment site using the
site locator tool
.
Provider Signature:
Date:
CDPH 8741 (4/20)
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