20-173 New Updates to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 1st Quarter 2020

Date: 03/02/20

This information applies to Participating Physician Groups (PPGs).

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

The updates are effective for dates of service on and after May 4, 2020

On January 14, 2020, the Pharmacy and Therapeutics (P&T) Committee approved updates to the Injectable Medication Healthcare Common Procedure Coding System (HCPCS)/Division of Financial Responsibility (DOFR) Crosswalk.

The approved updates, effective May 4, 2020, are listed on pages 2 and 3. Injectable medications are placed in DOFR categories that mirror the DOFR matrix categories in the Health Net* and CalViva Health Provider Participation Agreement (PPA).

The update includes:

• 12 new injectable medications and DOFR categories.
• 3 updates and changes to injectable medication procedure codes.
• 14 changes to existing DOFR categories.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on the provider website at provider.healthnet.com.

Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact
CalViva Health at 1-888-893-1569.

Additions to injectable medication HCPCS/DOFR crosswalk

The following medications have been approved by the P&T Committee as additions to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table. P&T Committee members include physicians and representatives from
Health Net participating physician groups (PPGs).

New drugs

HCPCS	Drug name	Generic name	Primary category	Secondary category
J3590	Adakveo®	Crizanlizumab-tmca IV solution	Therapeutic injection
J9118	Asparlas™	Calaspargase pegol-mknl, 10 units	Therapeutic injection	Chemotherapy*
J0179	Beovu®	Brolucizumab-dbll, 1 mg injection	Therapeutic injection
J9999	Enhertu®	Fam-trastuzumab deruxtecan-nxki for IV solution	Therapeutic injection	Chemotherapy*
J3490	Gilvaari™	Givosiran injection, for subcutaneous use	Therapeutic injection
J3490	Ketamine	Ketamine hcl injection	Therapeutic injection
J9999	Padcev™	Enfortumab vedotin-ejfv for IV solution	Therapeutic injection	Chemotherapy*
J3590	Reblozyl®	Luspatercept-aamt for subcutaneous inj	Therapeutic injection
J7401	Sinuva™	Mometasone furoate sinus implant, 10 micrograms	Therapeutic injection
J3490	Vyondys 53™	Golodirsen IV solution	Therapeutic injection
J3590	Xembify®	Immune globulin subcutaneous, human-klhw 20%	Therapeutic injection	Home health/infusion**
J3590	Ziextenzo®	Pegfilgrastim-bmez injection, for subcutaneous use	Self-injectable	Chemotherapy adjunctive*

 

Updates/changes to injectable medication procedure codes or medications

Updates to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table are based on changes or updates to HCPCS codes or changes in medication descriptions or availability. The following are changes to injectable medications currently listed in the crosswalk.

HCPCS	Drug name	Generic name	Comment
J9199	Infugem®	Gemcitabine hydrochloride, injection	Changed from J3590
J0642	Khapzory™	Levoleucovorin, 0.5 mg injection	Changed from J9999
C9055	Zulresso™	Brexanolone injection, for intravenous use	Changed from J3490

 

Category changes

The following medications have been approved by the Health Net P&T Committee to add the Secondary Category of Home Health Infusion.

HCPCS	Drug name	Generic name	Primary category	Secondary category
C9462	Baxdela®	Delafloxacin for injection, for intravenous use	Therapeutic injection	Home health/infusion**
J1833	Cresemba®	Isavuconazonium sulfate injection	Therapeutic injection	Home health/infusion**
J1267	Doribax®	Doripenem, 10 mg injection	Therapeutic injection	Home health/infusion**
J1290	Kalbitor®	Ecallantide injection	Therapeutic injection	Home health/infusion**
C9399, J3490	Noxafil®	Posaconazole injection	Therapeutic injection	Home health/infusion**
J3590	Nuzyra®	Omadacycline for injection	Therapeutic injection	Home health/infusion**
J2407	Orbactiv®	Oritavancin diphosphate for IV solution 400 mg	Therapeutic injection	Home health/infusion**
J3490	Prevymis™	Letermovir injection, for intravenous use	Therapeutic injection	Home health/infusion**
J3090	Sivextro®	Tedizolid phosphate injection	Therapeutic injection	Home health/infusion**
J0712	Teflaro™	Ceftaroline fosamil  Injection	Therapeutic injection	Home health/infusion**
J3490	Xerava™	Eravacycline dihydrochloride injection, for intravenous use	Therapeutic injection	Home health/infusion**
J0695	Zerbaxa®	Ceftolozane/tazobactam injection	Therapeutic injection	Home health/infusion**
J0565	Zinplava™	Bezlotoxumab injection, for intravenous use	Therapeutic injection	Home health/infusion**

HCPCS codes were taken from the Centers for Medicare & Medicaid Services (CMS) HCPCS website at www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.

*If associated with a ICD-10 cancer diagnosis.

**When administered by a nurse in a home setting.