20-892 Updates to the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 4th Quarter 2020
Date: 11/19/20
This information applies to Participating Physician Groups (PPGs).
To remain current, use the updates for dates of service on and after January 21, 2021
On October 13, 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 January 21, 2021, are listed in the tables below. Injectable medications are placed in DOFR categories that mirror the DOFR matrix categories in the Health Net Provider Participation Agreement (PPA).
The update includes:
- 12 new injectable medications and DOFR categories.
- 26 updates and changes to injectable medication procedure codes.
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 | Blenrep™ | Belantamab mafodotin-blmf for IV soln 100 mg | Therapeutic injection | Chemotherapy* |
J9145 | Darzalex® | Daratumumab IV soln 100 mg/5ml | Therapeutic injection | Chemotherapy* |
J0517 | Fasenra® pen | Benralizumab subcutaneous soln auto-injector 30 mg/ml | Self-injection |
|
J3590 | Kesimpta® | Ofatumumab soln auto-injector 20 mg/0.4ml | Self-injection |
|
C9399 | Monjuvi® | Tafasitamab-cxix For IV soln 200 MG | Therapeutic injection | Chemotherapy* |
J3490 | Monoferric™ | Ferric derisomaltose (one dose) IV soln 1000 mg/10ml | Therapeutic injection |
|
C9399 | Phesgo™ | Pertuzumab-trastuz-hyaluron-zzxf injection | Therapeutic injection | Chemotherapy* |
J9227 | Sarclisa® | Isatuximab-irfc IV soln 100 mg/5ml | Therapeutic injection | Chemotherapy* |
J9999 | Tecartus™ | Brexucabtagene Autoleucel Suspension for IV Infusion | Therapeutic injection | Chemotherapy* |
J3590 | Uplizna™ | Inebilizumab-cdon injection, for intravenous use | Therapeutic injection |
|
C9399 | Viltepso™ | Viltolarsen | Therapeutic injection |
|
C9399 | Zepzelca™ | Lurbinectedin for injection, for intravenous use | Therapeutic injection | Chemotherapy* |
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 |
|---|---|---|---|
90685 | Afluria® peds quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use | New Brand |
90687 | Afluria® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL, for intramuscular use | New Code |
J7196 | Atryn® | Antithrombin (Recombinant) | No longer manufactured |
90371 | Bayhep™ b | Hepatitis B Immune Globulin (HBIg), human, for intramuscular use | No longer manufactured |
90385 | Bayrho-d™ | Rh IG, minidose, IM | No longer manufactured |
J2788 | Bayrho-d™ | Rho d immune globulin, human, minidose, 50 mcg (250 iu) | No longer manufactured |
J2790 | Bayrho-d™ | Rho d immune globulin, human, minidose, 300 mcg (1500 iu) | No longer manufactured |
J1670 | Baytet™ | Tetanus immune globulin, human, up to 250 units | No longer manufactured |
J0490 | Benlysta® | Belimumab 10 mg | Replaces Q2044 |
J3120 | Delatestryl® | Testosterone enanthate injection, up to 100mg | No longer manufactured |
J3121 | Delatestryl® | Testosterone enanthate, 1 mg | No longer manufactured |
J3130 | Delatestryl® | Testosterone enanthate injection, up to 200mg | No longer manufactured |
J0886 | Epogen® | Epoetin alfa, 1000 units (for ESRD on dialysis) (renal dialysis facilities and hospitals must use code Q4081 effective 1/1/07) | Code deleted |
J3111 | Evenity® | Romosozumab-aqqg injection, for subcutaneous use | Replaces code J3590 |
90662 | Fluzone® high-dose | Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose is only indicated for those 65 years of age and older) | Revised description |
90694 | Fluad® quadrivalent | Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use | New Code |
J7192 | Genarc® | Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified | No longer manufactured |
J7190 | Monarc-m™ | Factor VIII (antihemophilic Factor [human]) per IU | No longer manufactured |
J7194 | Proplex® t factor ix complex | Factor IX, complex, per IU | No longer manufactured |
J7192 | Refacto® | Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified | No longer manufactured |
Q5105 | Retacrit® | Epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units | Updated Description |
Q5106 | Retacrit® | Epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units | Updated Description |
J7197 | Thrombate iii® | Antithrombin III (human), per IU | No longer manufactured |
J3032 | Vyepti™ | Eptinezumab-jjmr | New Code replaces J3590 |
J3490 | Zinbryta® | Daclizumab | No longer manufactured |
J1632 | Zulresso™ | Brexanolone injection, for intravenous use | New Code replaces C9055 |
HCPCS codes were taken from the Centers for Medicare & Medicaid Services HCPCS website.
*If associated with an ICD-10 cancer diagnosis.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update. .
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
| Line of Business | Telephone Number | Email Address |
|---|---|---|
| Cal Mediconnect – Los Angeles County | 1-855-464-3571 | provider_services@healthnet.com |
| Cal Mediconnect – San Diego County | 1-855-464-3572 | provider_services@healthnet.com |