Overview

Standard definitions determine the Division of Financial Responsibility (DOFR) categories into which injectable medications are placed and include brand names, generic names and associated HCPCS codes. The categories mirror the DOFR matrix categories located in the Health Net Provider Participation Agreement (PPA) DOFR agreement.

For Medi-Cal members under age 21 with California Children's Services (CCS)-eligible conditions, injectable medications used in the treatment of CCS-related conditions are not included in Health Net's coverage responsibilities under its Medi-Cal managed care contract with the Department of Health Care Services (DHCS).

Injectable medications are separated into two primary categories - therapeutic injections and self-injectables. These categories are sub-divided into secondary categories as follows:

• Therapeutic injections
  • Allergy serum
  • Blood and blood products for hemophilia (carved out for Medi-Cal)
  • Chemotherapy
  • Chemo adjunct
  • Home health/infusion
  • Immunizations
  • Immunosuppressants for transplants

• Self-injectables
  • Chemotherapy
  • Chemo adjunct
  • Growth hormones
  • HIV/AIDS
  • Infertility medications

  If an injectable medication does not have a secondary category, it defaults to the DOFR primary category. There are five secondary categories that are contingent on meeting specific criteria - chemotherapy, chemo adjunct injectable medications, HIV/AIDS, immunosuppressants for transplants and home health/infusion:

• Chemotherapy and chemo adjunct injectable medications must be associated with a cancer diagnosis using ICD-10 codes between C00.0-C79.9, C7A.00-C7B.8, C80.0-C96.9, D00.0-D09.9. If the appropriate codes are not used, these injectables default to the primary category
• HIV/AIDS must be associated with a HIV or AIDS diagnosis. If the diagnosis is not HIV or AIDS, these injectable medications default to the DOFR therapeutic category
• Home health infusion must be administered in the home by a nurse or physician. If it is not, this injectable medication defaults to the DOFR primary category
• Immunosuppressants for transplants must be associated with an organ transplant. If they are not, these injectable medications default to the DOFR primary category

Injectable medications are categorized using a standardized methodology to ensure clear and proper benefit administration and reimbursement. Chemotherapy, chemo adjunct, HIV/AIDS, home health/infusion, and immunosuppressants for transplants are the only injectable medications that may change categories depending on whether contingent criteria are met.

For additional current information regarding injectable medications, refer to the Health Net Injectable Medication HCPCS/DOFR Crosswalk (PDF) table.

Allergy testing agents and immune globulins given intramuscularly and subcutaneously that produce passive immunizations are classified as therapeutic injectable medications. Certain vaccines (for example, BCG) are categorized as chemotherapy or a therapeutic injection based on the appropriate indication.

Growth hormones and injectables considered safe for self-administration at home and packaged for this purpose are classified in the primary category of self-injectable medications.

Additional information regarding clinical guidelines and coverage criteria for injectable medications can be found in the Health Net Prior Authorization guidelines on the provider portal.

Hemophilia

Antihemophilic agents include hemophilic factors VIII and IX and factors used in the treatment of bleeding episodes in hemophilia A or B members with inhibitors to factor VIII or IX (for example, coagulation factor Vlla and anti-inhibitor coagulant complex). These agents must be used for Food and Drug Administration (FDA)-approved indications. Refer to the Health Net Injectable Medication HCPCS/DOFR Crosswalk table for more information.

Hemophilic factors are covered under the blood and blood products for hemophilia category. Refer to the Schedule of Benefits to determine coverage for these services. If services are covered under the member's plan, the services must be pre-approved and obtained from a participating provider.

For Medi-Cal members, blood and blood products for hemophilia are carved out and billed to Medi-Cal. For Medi-Cal members under age 21, hemophilia is a CCS-eligible condition and treatment is not included in Health Net's coverage responsibilities under its Medi-Cal managed care contract with the DHCS.