20-648 New Updates to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 3rd Quarter 2020
Date: 09/01/20
This information applies to Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
The updates are effective for dates of service on and after November 3, 2020
On July 14, 2020, the Health Net 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 November 3, 2020, are listed below. 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.
- 18 updates and changes to injectable medication procedure codes.
- 1 changes to existing DOFR categories.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email at provider_services@healthnet.com within 60 days.
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 |
C9059 | Anjeso™ | Meloxicam injection, for intravenous use | Therapeutic injection |
|
J3490 | Akovaz™ | Ephedrine sulfate injection, USP for intravenous use | Therapeutic injection |
|
Q5121 | Avsola™ | Injection, infliximab-axxq, biosimilar, 10mg | Therapeutic injection |
|
A9590 | Azedra® | Iobenguane I 131 injection, for intravenous use | Therapeutic injection | Chemotherapy* |
J3490 | Defitelio® | Defibrotide sodium injection, for intravenous use | Therapeutic injection |
|
J7204 | Esperoct® | Antihemophilic factor (recombinant), glycopegylated-exei is a coagulation Factor VIII concentrate indicated for use in adults and children with hemophilia A | Therapeutic injection | Blood/blood products for hemophilia |
A9513 | Lutathera® | Lutetium Lu 177 dotatate injection, for intravenous use | Therapeutic injection | Chemotherapy* |
J1201 | Quzyttir™ | Cetirizine hydrochloride injection, for intravenous use | Therapeutic injection |
|
C9399 | Sarclisa® | Isatuximab-irfc injection, for intravenous use | Therapeutic injection | Chemotherapy* |
J9999 | Trodelvy™ | Sacituzumab govitecan-hziy for injection, for intravenous use | Therapeutic injection | Chemotherapy* |
J7333 | Visco-3™ | Hyaluronan or derivative for intra-articular injection, per dose | Therapeutic injection |
|
J0691 | Xenleta™ | Lefamulin injection, for intravenous use | Therapeutic injection | Home health/infusion** |
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 |
J1815 | Insulin | Injection, insulin, per 5 units | Clarification |
J0791 | Adakveo® | Crizanlizumab-tmca IV Solution | Updated from J3590,C9053 |
J9245 | Alkeran® | Melphalan hydrochloride, not otherwise specified, 50 mg | Updated description |
J7169 | Andexxa® | Injection, coagulation factor Xa (recombinant), inactivated | Updated from C9041 |
J9246 | Evomela® | Melphalan 1 mg | Updated from J9245 |
J9358 | Enhertu® | Fam-trastuzumab deruxtecan-nxki for IV Solution | Updated from J9999 |
J0223 | Gilvaari™ | Givosiran injection, for Subcutaneous use | Updated from J3490, C9056 |
J9198 | Infugem® | Gemcitabine hydrochloride, Injection | Updated from J1999 |
J9177 | Padcev™ | Enfortumab vedotin-ejfv for IV Solution | Updated from J9999 |
J0742 | Recarbrio™ | Imipenem, cilastatin, and relebactam for injection, for intravenous use | Updated from J3490 |
J0896 | Reblozyl® | Luspatercept-aamt for Subcutaneous inj | Updated from J3590 |
Q5119 | Ruxience™ | Rituximab-pvvr (Rituxan biosimilar) | Updated from J1999 |
C9122 | Sinuva™ | Mometasone furoate sinus implant, 10 micrograms | Updated from J7401 |
C9061 | Tepezza™ | Atezolizumab | Updated from J3590 |
J1429 | Vyondys 53™ | Golodirsen IV Solution | Updated from J3490 |
J1558 | Xembify® | Immune Globulin Subcutaneous, human-klhw 20% | Updated from J3590 |
Q5120 | Ziextenzo™ | Pegfilgrastim-bmez injection, for Subcutaneous use | Updated from J3590 |
J3399 | Zolgensma™ | Onasemnogene abeparvovec-xioi | Updated from J3490 |
Category changes The following medication has been approved by the Health Net P&T Committee to add the Secondary Category of Home Health Infusion.
|
HCPCS codes were taken from the Centers for Medicare & Medicaid Services (CMS) HCPCS website.
*If associated with an ICD-10 cancer diagnosis.
**When administered by a nurse in a home setting.