22-662 Stay Current with the Injectable Medication HCPCS/DOFR Crosswalk Reference Table - 3rd Quarter 2022
Date: 08/25/22
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 31, 2022
On July 12, 2022, 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 31, 2022, are listed below of this Provider Update. 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 to be added to the DOFR crosswalk.
- 20 updates and changes to injectable medication procedure codes.
- Two updates to a DOFR category.
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 |
|---|---|---|---|---|
J3590 | Alymsys® | Bevacizumab-maly injection, for intravenous use | Therapeutic injection | Chemotherapy1 |
J3490 | Amvuttra™ | Vutrisiran injection, for subcutaneous use | Therapeutic injection |
|
Q0222 | Bebtelovimab | Bebtelovimab IV solution 175 mg/2ml | Therapeutic injection |
|
C9999 | Besremi® | Ropeginterferon alfa-2b-njft injection, for subcutaneous use | Therapeutic injection | Chemotherapy1 |
J3490 | Evusheld™ | Tixagevimab 150 Mg/1.5ml and Cilgavimab 150 Mg/1.5ml IM Solution | Therapeutic injection2 |
|
J0879 | Korsuva™ | Difelikefalin injection, for intravenous use | Therapeutic injection |
|
J3590 | Mounjaro™ | Tirzepatide Injection, for subcutaneous use | Self-injectable |
|
J9999 | Opdualag™ | Nivolumab and relatlimab-rmbwinjection, for intravenous use | Therapeutic injection | Chemotherapy1 |
J3490 | Rezipres® | Ephedrine hydrochloride injection for intravenous use | Therapeutic injection |
|
J9359 | Zynlonta® | Loncastuximab tesirine-lpyl, for injection, for intravenous use | Therapeutic injection | Chemotherapy1 |
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 |
|---|---|---|---|
J0739 | Apretude™ | Cabotegravir extended-release injectable suspension, for intramuscular use | Replaces J3490 |
C9098 | Carvykti™ | Ciltacabtagene autoleucel suspension for intravenous infusion | Replaces J3590 |
J9080 | Cyclophosphamide | Cyclophosphamide 200 mg injection | Code Deleted |
J9090 | Cyclophosphamide | Cyclophosphamide 500 mg injection | Code Deleted |
J9091 | Cyclophosphamide | Cyclophosphamide 1.0 gram injection | Code Deleted |
J9092 | Cyclophosphamide | Cyclophosphamide 2.0 gram injection | Code Deleted |
C9087 | Cyclophosphamide | Injection, cyclophosphamide, (AuroMedics), 10 mg | Code Deleted |
C9094 | Enjaymo™ | Sutimlimab-jome injection, for intravenous use | Replaces J3591 |
J9331 | Fyarro™ | Sirolimus protein-bound particles for IV | Replaces J3590 |
C9095 | Kimmtrak® | Tebentafusp-tebn IV solution 100 mcg/0.5m | Replaces J3590 |
J1306 | Leqvio® | Inclisiran injection, for subcutaneous use | Replaces J3490 |
J0219 | Nexviazyme™ | Injection, aducanumab-avwa, 2 mg | Replaces C9085 |
C9096 | Releuko™ | Filgrastim-ayow injection solution 300 mcg/ml | Replaces J3590 |
J2998 | Ryplazim® | Plasminogen, human-tvmh | Replaces J3590 |
J0491 | Saphnelo™ | Anifrolumab-fnia injection, for intravenous use | Replaces C9086 |
J2779 | Susvimo™ | Ranibizumab injection for intravitreal use (Ocular Implant) | Replaces J3590 |
J2356 | Tezspire™ | Tezepelumab-ekko injection, for subcutaneous use | Replaces J3590 |
C9097 | Vabysmo™ | Faricimab-svoa intravitreal injection 6 mg/0.05ml | Replaces J3590 |
J9332 | Vyvgart™ | Efgartigimod alfa-fcab injection, for intravenous use | Replaces J3590 |
J3299 | Xipere™ | Triamcinolone acetonide injectable suspension, for suprachoroidal use | Replaces J3490 |
Category changes
The following medications have been approved by the Health Net Pharmacy and Therapeutics Committee to add the Secondary Category listed below.
HCPCS | Drug name | Generic name | Primary category | Secondary category |
|---|---|---|---|---|
J0741 | Cabenuva™ | Cabotegravir and rilpivirine | Therapeutic injection | HIV/AIDS |
C9098 | Carvykti™ | Ciltacabtagene autoleucel suspension for intravenous infusion | Therapeutic injection | Chemotherapy1 |
HCPCS codes were taken from the Centers for Medicare & Medicaid Services HCPCS.
1If 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.
2A request to add “immunization” as secondary category was denied as the drug is not an immunization.
Additional information
Relevant sections of Health Net’s* 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 after logging in to
Health Net’s provider website > Provider Library under Quick Links, or go directly to provider library.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by phone or through the Health Net provider website.