21-797 Stay Current with the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 4th Quarter 2021
Date: 11/17/21
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 January 28, 2022
On October 12, 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 January 28, 2022, 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:
- 15 new injectable medications and DOFR crosswalk.
- 35 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).
HCPCS | Drug name | Generic name | Primary category | Secondary category |
|---|---|---|---|---|
C9399, J3590 | Aduhelm™ | Aducanumab-avwa IV Solution | Therapeutic injection |
|
C9399, J3490 | Empaveli™ | Pegcetacoplan subcutaneous Solution 1080 mg/20ml | Therapeutic injection |
|
C9399, J3590 | Nexviazyme™ | Avalglucosidase alfa-ngpt | Therapeutic injection |
|
J9318 | Romidepsin | Romidepsin, non-lyophilized, 0.1 mg | Therapeutic injection | Chemotherapy1 |
J9319 | Romidepsin | Romidepsin, lyophilized, 0.1 mg | Therapeutic injection | Chemotherapy1 |
C9399 | Rybrevant™ | Amivantamab-vmjw | Therapeutic injection | Chemotherapy1 |
J3490 | Wegovy™ | Semaglutide injection,2.4mg for subcutaneous use | Self-injectable |
|
90662 | Fluzone® high-dose quadrivalent | Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone high-dose is only indicated for individuals age 65 and older) | Therapeutic injection | Immunization |
90686 | Fluzone ® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 ml dosage, for intramuscular use | Therapeutic injection | Immunization |
90686 | Flulaval® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 ml dosage, for intramuscular use | Therapeutic injection | Immunization |
90686 | Afluria® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 ml dosage, for intramuscular use | Therapeutic injection | Immunization |
90687 | Fluzone® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 ml, for intramuscular use | Therapeutic injection | Immunization |
90688 | Afluria® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 ml dosage, for intramuscular use | Therapeutic injection | Immunization |
90688 | Fluzone® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 ml dosage, for intramuscular use | Therapeutic injection | Immunization |
J2182 | Nucala Autoinjector | Injection, mepolizumab, 1 mg Auto-injector 00173-0892-01 | Self-injectable |
|
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 |
|---|---|---|---|
90656 | Afluria® preservative free suspension | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 ml dosage, for intramuscular use | Remove. No longer active |
Q2035 | Afluria® suspension | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use (Afluria) see also 90656 and 90658 | Remove. No longer active |
A9590 | Azedra® | Iobenguane I 131 injection, for intravenous use | Radiopharmaceuticals are not a DOFR category |
Q0239 | Bamlanivimab | Injection, bamlanivimab-xxxx, 700 mg | Code deleted |
Q2054 | Breyanzi® | Lisocabtagene maraleucel suspension for intravenous infusion | Replaces J9999 |
J0741 | Cabenuva™ | Cabotegravir suspension Extended Release cabotegravir extended-release injectable suspension; rilpivirine extended-release injectable suspension), co-packaged for intramuscular use 600&900mg/3ml, 400&600mg/2ml | Replaces J3490 |
J1448 | Cosela™ | Trilaciclib for injection, for intravenous | Replaces J3490 |
J9100 | Cytarabine | Cytarabine hcl 100 mg injection | Replaces J9110 |
J9110 | Cytarabine | Cytarabine, 500mg | No longer available |
J1305 | Evkeeza™ | Evinacumab-dgnb injection, for intravenous | Replaces J3590 |
J0699 | Fetroja® | Injection, cefiderocol, 10 mg | Replaces J3490 |
J0693 | Fetroja® | Injection, cefiderocol, 5 mg | Replaces J3490 |
90653 | Fluad™ suspension | Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use | Remove. No longer active |
90673 | Flublok® | Influenza vaccine, recombinant hemagglutinin antigens, for intramuscular use | Remove. No longer active |
Q2036 | Flulaval® | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use (Flulaval) | Remove. No longer active |
90688 | Flulaval® quadrivalent | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 ml dosage, for intramuscular use | Remove. No longer active |
90672 | Flumist® quadrivalent | Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use | Remove. Non-injectable -available under Pharmacy |
Q2036 | Fluogen® | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
Q2036 | Flushield® influenza virus vaccine | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
Q2037 | Fluvirin® | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
90658 | Fluvirin® injection | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use (Code price is per 0.5 ml based on Fluzone which is indicated for individuals age 3 and older) (Fluvirin is indicated for those individuals age 4 and older-code price for these patients would be $14.46 per 0.5 ml. FluLaval and Afluria are indicated for those 18 years of age and older- | Remove. No longer active |
Q2036 | Fluvirin® injection | Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Code price is per 0.5 ml based on Fluzone for patients age 3 through 17 years old.) | Remove. No longer active |
90656 | Fluvirin® injection preservative free | Influenza virus vaccine, split virus, preservative free, when administered to individuals age 3 and older, for intramuscular use. (Please note: Agriflu is only indicated for use in patients 18 years of age and older) | Remove. No longer active |
90630 | Fluzone® | Intradermal Quadrivalent (Influenza Vaccine) | Remove. No longer active |
Q2038 | Fluzone® | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
Q2039 | Fluzone® high-dose suspension | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
Q2038 | Fluzone® injection | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use (Fluzone) | Remove. No longer active |
Q2038 | Fluzone® pediatric pf | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
90656 | Fluzone® preservative free suspension | Influenza virus vaccine, split virus, preservative free, when administered to individuals age 3 and older, for intramuscular use. (Please note: Agriflu is only indicated for use in patients age 18 and older) | Remove. No longer active |
90655 | Fluzone® pediatric pf suspension | Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use | Remove. No longer active |
Q2038 | Fluzone® preservative free suspension | Influenza virus vaccine, split virus, when administered to individuals age 3 and older, for intramuscular use | Remove. No longer active |
J7326 | Gel-One | Hyaluronan or derivative, Gel-One, for intra-articular injection | Replaces J1080 |
J9247 | Pepaxto® | Melphalan flufenamide for IV, 20 MG | Replaces J9999 |
J9318 | Romidepsin | Injection, romidepsin, nonlyophilized, 0.1 mg | Replaces C9065 |
J9319 | Romidepsin | Injection, romidepsin, lyophilized, 0.1 mg | Replaces C9065 |
HCPCS codes were taken from the Centers for Medicare & Medicaid Services HCPCS website.
1 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.
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 within 60 days, by telephone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
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 | provider_services@healthnet.com | |
Cal MediConnect – San Diego County | 1-855-464-3572 |