21-581 Stay Current with the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 3rd Quarter 2021
Date: 08/18/21
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.
Use the updates for dates of service on and after October 21, 2021
On July 13, 2021, 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 October 21, 2021, are listed 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:
- 10 new injectable medications and DOFR categories.
- 19 updates and changes to injectable medication procedure codes.
- 2 changes to existing DOFR categories.
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).
HCPCS | Drug name | Generic name | Primary category | Secondary category |
|---|---|---|---|---|
J9999 | Abecma® | Idecabtagene vicleucel, suspension for intravenous infusion | Therapeutic injection | Chemotherapy* |
J3490 | Artesunate™ | Artesunate 110 mg Solution Reconstituted | Therapeutic injection |
|
J3590 | Curosurf® | Poractant alfa intratracheal suspension | Therapeutic injection |
|
J9348 | Danyelza® | Naxitamab-gqgk 40 mg/10 ml Solution Injection, 1 mg | Therapeutic injection | Chemotherapy* |
J1951 | Fensolvi® | Leuprolide acetate for injectable suspension, | Therapeutic injection |
|
J9999 | Jemperli® | Dostarlimab-gxly | Therapeutic injection | Chemotherapy* |
J9353 | Margenza™ | Injection, margetuximab-cmkb, 5 mg | Therapeutic injection | Chemotherapy* |
Q0243 | Regen-cov™ | Injection, casirivimab and imdevimab, 2400 mg | Therapeutic injection |
|
J3490 | Sotradecol® | Sodium Tetradecyl Sulfate Injection | Therapeutic injection |
|
J9999 | Zynlonta™ | Loncastuximab tesirine-lpyl for Injection,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 |
|---|---|---|---|
C9075 | Amondys 45™ | Casimersen injection, for intravenous use | Replaces J3490 |
J1943 | Aristada Initio® | Aripiprazole lauroxil extended-release injectable suspension | Replaces C9133 |
J1944 | Aristada® | Aripiprazole lauroxil intramuscular (IM) ER suspension prefilled syringe | Replaces J1942 |
Q0239 | Bamlanivimab | Injection, bamlanivimab-xxxx, 700 mg | Removed. No longer approved by FDA |
C9076 | Breyanzi® | Lisocabtagene maraleucel suspension for intravenous infusion | Replaces J9999 |
C9077 | Cabenuva™ | Cabotegravir suspension Extended Release cabotegravir extended-release injectable suspension; rilpivirine extended-release injectable suspension, co-packaged for intramuscular use | Replaces J3490 |
C9078 | Cosela™ | Trilaciclib for injection, for intravenous | Replaces J3490 |
J9144 | Darzalex Faspro™ | Injection, daratumumab 10 mg and hyaluronidase-fihj | Replaces C9062 |
C9079 | Evkeeza™ | Evinacumab-dgnb injection, for intravenous | Replaces J3590 |
J1561 | Gammaked™ | Injection, immune globulin, intravenous, non-lyophilized, e.g. liquid | Replaces J1599 |
J1557 | Gammaplex® | Immune Globulin Intravenous [Human], 5% Liquid, for intravenous use | Replaces C9270 |
J9281 | Jelmyto® | Mitomycin pyelocalyceal instillation, 1 mg | Replaces C9064 |
J7168 | Kcentra® | Prothrombin Complex Concentrate (Human) for Intravenous Use | Replaces C9132 |
J0224 | Oxlumo™ | Injection, lumasiran, 0.5 mg | Replaces J3490 |
J1599 | Panzyga® | Immune globulin, intravenous, non-lyophilized (e.g. liquid), | Replaces J3590 |
C9080 | Pepaxto® | Melphalan flufenamide For IV, 20 mg | Replaces J9999 |
J3490 | Protonix® Iv | Pantoprazole sodium, 40 mg for IV Infusion | Replaces C9035 |
J9314 | Romidepsin® | Injection romidepsin non-lypohilized 1mg (5 mg/ml | Replaces C9065 |
J3490 | Zyprexa® | Olanzapine, 2.5 mg | Replaces S0166 |
Category changes
The following medications have been approved by the Health Net Pharmacy and Therapeutics Committee to add the Secondary Category of Home Health Infusion.
HCPCS | Drug name | Generic name | Primary category | Secondary category |
|---|---|---|---|---|
J2350 | Ocrevusi® | Ocrelizumab injection, for intravenous use | Therapeutic injection | Home health/infusion** |
J1303 | Ultomiris® | Ravulizumab-cwvz injection, for intravenous use | Therapeutic injection | Home health/infusion** |
HCPCS codes were taken from the Centers for Medicare & Medicaid Services HCPCS website.
* If associated with a cancer diagnosis- ICD-10 codes between C00.0-C79.9, C7A.00-C7B.8, C80.0-C96.9, D00.0-D09.9.
** When administered by a nurse in a home setting.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website as listed below.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by telephone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 |
| |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 |
| |
Medicare (individual) | 1-800-929-9224 |
| |
Medicare (employer group) | 1-800-929-9224 |
| |
Medi-Cal | 1-800-675-6110 |
| N/A |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | N/A | provider_services@healthnet.com |
Cal MediConnect – San Diego County | 1-855-464-3572 | N/A | provider_services@healthnet.com |