20-379 New Updates to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 2nd Quarter 2020

Date: 05/07/20

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 July 9, 2020

On May 7, 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 July 9, 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:

• 8 new injectable medications and DOFR categories.
• 8 updates and changes to injectable medication procedure codes.
• 16 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 Health Net 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
C9399	Asceniv™	Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid)	Therapeutic injection	Home health/infusion**
J3490	Giapreza™	Angiotensin II injection for intravenous infusion	Therapeutic injection
J2505	Neulasta® Onpro® kit	6 mg/0.6 mL pegfilgrastim in a single-dose prefilled syringe co-packaged with the on-body injector (OBI)	Therapeutic injection	Chemotherapy adjunctive*
J3490	Recarbrio™	Imipenem, cilastatin and relebactam for injection, for intravenous use	Therapeutic injection	Home health/infusion**
J9999	Ruxience™	Rituximab-pvvr (rituxan biosimilar)	Therapeutic injection	Chemotherapy*
J3590	Tepezza™	Atezolizumab	Therapeutic injection
J9999	Unituxin™	Dinutuximab injection, for intravenous use	Therapeutic injection	Chemotherapy adjunctive*
J3590	Vyepti™	Eptinezumab-jjmr	Therapeutic injection

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
C9041	Andexxa®	Injection, coagulation factor Xa (recombinant), inactivated	Replaces J3590
J1826	Avonex®	Interferon beta-1a	Replaces Q3025
J9212	Infergen®	Interferon alfacon-1	Code deleted
J0945	Nd-stat	Brompheniramine maleate injection	No longer manufactured
J3420	Nervidox S™	Vitamin B-12 cyanocobalamin, up to 1,000 mcg	No longer manufactured
J2355	Neumega®	Oprelvekin injection	No longer manufactured
J9213	Roferon-A®	Interferon alfa-2a, recombinant, 3 million units	Code deleted – No longer manufactured
J0593	Takhzyro®	Landelumab-flyo	Replaces J3590

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
J2505	Neulasta®	Pegfilgrastim, per 6 mg	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
C9058	Ziextenzo®	Pegfilgrastim-bmez injection, for subcutaneous use	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
Q5111	Udenyca®	Pegfilgrastim-cbqv, biosimilar, 0.5 mg	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
Q5108	Fulphila®	Pegfilgrastim-jmdb, biosimilar, 0.5 mg	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
Q5101	Zarxio®	Filgrastim-sndz injection, biosimilar, 1 microgram	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
J1447	Granix®	Tbo-filgrastim, 1 microgram	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)
Q5110	Nivestym®	Filgrastim-aafi, biosimilar, 1 microgram	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant  drugs (G-CSF with mozobil)
J1442	Neupogen®	Filgrastim (G-CSF), excludes biosimilars, 1 microgram	Self-injectable	Chemotherapy adjunctive*
			Therapeutic injection	Transplant drugs (G-CSF with mozobil)

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.