22-067 Stay Current with the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 1st Quarter 2022
Date: 02/11/22
This information applies to Participating Physician Groups (PPGs).
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Use the updates for dates of service on and after April 18, 2022
On January 11, 2022, 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 April 18, 2022, are 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:
- 11 new injectable medications to be added to the DOFR crosswalk.
- 16 updates and changes to injectable medication procedure codes.
- 1 update to a DOFR category.
Additions to injectable medication HCPCS/DOFR crosswalk
The following medications have been approved by the 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 |
|---|---|---|---|---|
J1952 | Camcevi™ | Leuprolide injectable, 1 mg | Therapeutic injection | Chemotherapy1 |
C9087 | Cyclophosphamide | Injection, cyclophosphamide, (AuroMedics), 10 mg | Therapeutic injection | Chemotherapy1 |
J3590 | Fyarro™ | Sirolimus protein-bound particles for IV | Therapeutic injection | Chemotherapy1 |
J2046 | Kimyrsa™ | Oritavancin diphosphate for IV solution 1200 Mg | Therapeutic injection |
|
90677 | Prevnar 20™ | Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use | Therapeutic injection | Immunization |
J9021 | Rylaze ™ | Asparaginase erwinia chrysanthemi (recombinant) rywn injection, for intramuscular use | Therapeutic injection | Chemotherapy adjunctive1 |
C9086 | Saphnelo™ | Anifrolumab-fnia) injection for intravenous use | Therapeutic injection |
|
Q0247 | Sotrovimab | Sotrovimab 500MG/8ML solution | Therapeutic injection |
|
90671 | Vaxneuvance™ | Pneumococcal 15-valent conjugate Vaccine) | Therapeutic injection | Immunization |
J1445 | Triferic® avnu | Ferric pyrophosphate citrate solution 0.1 mg of iron | Therapeutic injection |
|
J3490 | Apretude™ | Cabotegravir extended-release injectable suspension), for intramuscular use | 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 |
|---|---|---|---|
Q2055 | Abecma® | Idecabtagene vicleucel | Replaces J3590 |
J0172 | Aduhelm™ | Aducanumab-avwa IV solution | Replaces J3590 |
J1426 | Amondys 45™ | Casimersen injection, 10 mg | Replaces C9075 |
J2430 | Aredia® | Pamidronate disodium | No longer manufactured |
J9269 | Elzonris® | Tagraxofusp-erzs | Replaces J9296 |
J9272 | Jemperli® | Injection, dostarlimab-gxly, 10 mg | Replaces C9999 |
C9085 | Nexviazyme™ | Injection, aducanumab-avwa, 2 mg | Replaces J3590 |
J2506 | Neulasta® | Injection, pegfilgrastim, excludes biosimilar, 0.5 mg (self-injectable) | Replaces J2505 |
J2506 | Neulasta® | Injection, pegfilgrastim, excludes biosimilar, 0.5 mg (therapeutic Injection) | Replaces J2505 |
J0890 | Omontys® | Peginesatide acetate solution injection | No longer manufactured |
J2940 | Protropin® | Somatrem for Injection | No longer manufactured |
J9061 | Rybrevant™ | Injection, amivantamab-vmjw, 2 mg | Replaces C9399 |
J2941 | Tev-tropin® | Somatropin, 1 mg | No longer manufactured |
J3315 | Trelstar® depot | Triptorelin pamoate for intramuscular (IM) injection | No longer manufactured |
J3315 | Trelstar® la | Triptorelin pamoate for intramuscular (IM) injection | No longer manufactured |
J7310 | Vitrasert® | Ganciclovir intravitreal ophthalmic implant | No longer manufactured |
Category changes
The following medications have been approved by the Health Net Pharmacy and Therapeutics committee.
HCPCS | Drug name | Generic name | Primary category | Secondary category |
|---|---|---|---|---|
J2357 | Xolair® | Omalizumab, 5 mg | Therapeutic injection |
|
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.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.