No. J0738 is a HCPCS Level II code, maintained by CMS, that identifies the drug supplied. CPT codes are five-digit numbers from the AMA that describe services. Giving the drug, for example an injection or infusion, is usually reported with a separate CPT administration code.

What is the Medicare payment limit for J0738?

$16.016 per 1 mg, effective October 1, 2026 through December 31, 2026, from CMS's Part B drug payment limit file. Multiply by the units billed for the allowed amount before deductible and coinsurance. It is not a coverage decision.

What is one billing unit of J0738?

One unit of J0738 is 1 mg, as stated in the code's descriptor. Units to report = dose given ÷ 1 mg.

J0738 J-Code: Lenacapavir — Billing Units & NDCs

In short

J0738 is the HCPCS Level II code for injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv). One billing unit is 1 mg. The Medicare Part B payment limit is $16.016 per unit (October 1, 2026 through December 31, 2026).

Code

CMS HCPCS file

HCPCS codeJ0738

Billing unit1 mg

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 set: HCPCS Level II, maintained by CMS
Effective: Oct 1, 2025

The billing unit is read from the descriptor. Confirm it against the CMS file before billing.

Medicare Part B payment limit

CMS ASP file

Payment limit per unit$16.016

Per1 mg

Coinsurance0%

Effective October 1, 2026 through December 31, 2026. Payment allowance limits subject to the ASP methodology are based on 2Q26 ASP data. CMS note: HIV PrEP drug. A payment limit is not a coverage decision; the Medicare contractor decides coverage. CMS ASP pricing files

Units and claim line

Units = dose given ÷ 1 mg. For example, 100 mg is 100 units. Enter the dose to get the units and the NDC line for the CMS-1500 and the 837P.

Dose given (mg)

HCPCS units (1 unit = 1 mg)

Modifier

NDC (11-digit)

NDC unit qualifier

NDC quantity

Enter the dose given to build the claim line.

Find the NDC

Med-Code hasn’t mapped J0738 to specific products yet. Search the FDA NDC Directory for the drug named in the descriptor, and check the route and strength match the code.

Search NDCs for lenacapavir

J0738: common questions

Is J0738 a CPT code?: No. J0738 is a HCPCS Level II code, maintained by CMS, that identifies the drug supplied. CPT codes are five-digit numbers from the AMA that describe services. Giving the drug, for example an injection or infusion, is usually reported with a separate CPT administration code. CPT codes for drug administration.
What is the Medicare payment limit for J0738?: $16.016 per 1 mg, effective October 1, 2026 through December 31, 2026, from CMS's Part B drug payment limit file. Multiply by the units billed for the allowed amount before deductible and coinsurance. It is not a coverage decision.
What is one billing unit of J0738?: One unit of J0738 is 1 mg, as stated in the code's descriptor. Units to report = dose given ÷ 1 mg. J-code billing units.

J0738 — Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)