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Injectable Medication Hcpcs/Dofr Crosswalk INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY J0287 ABELCET Amphotericin B lipid complex THERAPEUTIC INJ HOME HEALTH/INFUSION** J0400 ABILIFY Aripiprazole, intramuscular, 0.25 mg THERAPEUTIC INJ J0401 ABILIFY MAINTENA Apriprazole 300mg, IM injection THERAPEUTIC INJ J9264 ABRAXANE Paclitaxel protein-bound particles, 1 mg THERAPEUTIC INJ CHEMOTHERAPY* J1120 ACETAZOLAMIDE SODIUM Acetazolamide sodium injection THERAPEUTIC INJ J0132 ACETYLCYSTEINE INJ Acetylcysteine injection, 10 mg THERAPEUTIC INJ ACTEMRA 162mg/0.9ml Syringe (50242- J3262 Tocilizumab, 1 mg SELF-INJECTABLE 0138-01) ACTEMRA INJECTION (50242-0136- J3262 Tocilizumab 200mg, 400mg THERAPEUTIC INJ HOME HEALTH/INFUSION** 01, 50242-0137-01) J0800 ACTHAR HP Corticotropin injection THERAPEUTIC INJ Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4- 90648 ACTHIB THERAPEUTIC INJ IMMUNIZATIONS dose schedule), for intramuscular use J0795 ACTHREL Corticorelin Ovine Triflutal THERAPEUTIC INJ J9216 ACTIMMUNE Interferon gamma 1-b 3 miillion units SELF-INJECTABLE CHEMO ADJUNCT* J2997 ACTIVASE Alteplase recombinant, 1mg THERAPEUTIC INJ HOME HEALTH/INFUSION** J0133 ACYCLOVIR SODIUM Acyclovir, 5 mg THERAPEUTIC INJ HOME HEALTH/INFUSION** 90715 ADACEL Tdap vaccine, > 7 yrs, IM THERAPEUTIC INJ IMMUNIZATIONS J2504 ADAGEN Pegademase bovine, 25 IU THERAPEUTIC INJ HOME HEALTH/INFUSION** J0791 ADAKVEO Crizanlizumab-tmca IV Solution THERAPEUTIC INJ HOME HEALTH/INFUSION** J9042 ADCETRIS Brentuximab vedotin Injection THERAPEUTIC INJ CHEMOTHERAPY* J0153 ADENOCARD Adenosine 6 MG THERAPEUTIC INJ C9399, J3490 ADLYXIN Lixisenatide Solution SELF-INJECTABLE J0171 ADRENALIN Adrenalin (epinephrine) inject THERAPEUTIC INJ J9000 ADRIAMYCIN Doxorubicin hcl 10 MG THERAPEUTIC INJ CHEMOTHERAPY* J9190 ADRUCIL Fluorouracil injection, 500 mg THERAPEUTIC INJ CHEMOTHERAPY* Factor VIII (antihemophilic factor, recombinant) per IU, not BLOOD/BLOOD PRODUCTS FOR J7192 ADVATE THERAPEUTIC INJ otherwise specified HEMOPHILIA Antihemophilic Factor (Recombinant), PEGylated, is a BLOOD/BLOOD PRODUCTS FOR J7207 ADYNOVATE THERAPEUTIC INJ human antihemophilic factor HEMOPHILIA Influenza virus vaccine, quadrivalent (IIV4), split virus, AFLURIA Peds Quadrivalent 90685 preservative free, 0.25 mL dosage, for intramuscular use THERAPEUTIC INJ IMMUNIZATIONS AFLURIA PRESERVATIVE FREE Influenza virus vaccine, trivalent (IIV3), split virus, 90656 THERAPEUTIC INJ IMMUNIZATIONS SUSP preservative free, 0.5 mL dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 90687 AFLURIA Quadrivalent THERAPEUTIC INJ IMMUNIZATIONS mL, for intramuscular use Influenza virus vaccine, split virus, when administered to Q2035 AFLURIA SUSP individuals 3 years of age and older, for intramuscular use THERAPEUTIC INJ IMMUNIZATIONS (Afluria) see also 90656 and 90658 * 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 Rev. April 13, 2021 ** When administered by a nurse in a home setting Page 1 of 39 Effective July 16, 2021 INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY BLOOD/BLOOD PRODUCTS FOR J7210 AFSTYLA Injection, factor VIII, antihemophilic factor,recombinant THERAPEUTIC INJ HEMOPHILIA J3246 AGGRASTAT Tirofiban HCl, 0.25 mg THERAPEUTIC INJ Q2034 AGRIFLU Influenza virus vaccine, split virus, for intramuscular use THERAPEUTIC INJ IMMUNIZATIONS J1720 A-HYDROCORT Hydrocortisone sodium succinate THERAPEUTIC INJ CHEMO ADJUNCT* J3590 AIMOVIG Erenumab-aooe injection, for subcutaneous use SELF-INJECTABLE J3031 AJOVY Fremanezumab-vfrm SELF-INJECTABLE J0190 AKINETON Biperiden lactate, per 5 mg THERAPEUTIC INJ J3490 AKOVAZ Ephedrine sulfate injection, USP for intravenous use THERAPEUTIC INJ Fosnetupitant and palonsetron) for injection, for J1454 AKYNZEO THERAPEUTIC INJ CHEMO ADJUNCT* intravenous use J1931 ALDURAZYME Laronidase injection THERAPEUTIC INJ HOME HEALTH/INFUSION** Interferon alfa-N3 (human leukocyte derived), 250,000 IU J9215 ALFERON N SELF-INJECTABLE CHEMO ADJUNCT* inj J9305 ALIMTA Pemetrexed, 10 mg THERAPEUTIC INJ CHEMOTHERAPY* J9057 ALIQOPA Copanlisib for injection, for intravenous use THERAPEUTIC INJ CHEMOTHERAPY* J9245 ALKERAN Melphalan hydrochl 50 MG THERAPEUTIC INJ CHEMOTHERAPY* J2469 ALOXI Palonosetron HCl, 25 mcg THERAPEUTIC INJ CHEMO ADJUNCT* BLOOD/BLOOD PRODUCTS FOR J7190 ALPHANATE Factor VIII (antihemophilic Factor [human]) per IU THERAPEUTIC INJ HEMOPHILIA Von Willebrand Factor complex, human, ristocetin BLOOD/BLOOD PRODUCTS FOR J7186 ALPHANATE VWF THERAPEUTIC INJ coFactor (not otherwise specified ), per I.U. HEMOPHILIA Factor IX (antihemophilic Factor, purified, non- BLOOD/BLOOD PRODUCTS FOR J7193 ALPHANINE SD THERAPEUTIC INJ recombinant) per IU HEMOPHILIA Coagulation Factor IX (Recombinant), Fc Fusion Protein], BLOOD/BLOOD PRODUCTS FOR J7201 ALPROLIX THERAPEUTIC INJ Lyophilized Powder for Solution for Intravenous Injection HEMOPHILIA Injection, alprostadil, 1.25 mcg (code may be used for J0270 Alprostadil 500 Medicare when drug administered under direct physician SELF-INJECTABLE supervision, not for use when drug is self-administered) J0289 AMBISOME Amphotericin B liposome inj THERAPEUTIC INJ HOME HEALTH/INFUSION** J2920 A-METHAPRED Methylprednisolone injection THERAPEUTIC INJ CHEMO ADJUNCT* J2930 A-METHAPRED Methylprednisolone injection THERAPEUTIC INJ CHEMO ADJUNCT* J0215 AMEVIVE Alefacept THERAPEUTIC INJ S0017 AMICAR Aminocaproic acid THERAPEUTIC INJ AMIKACIN SULF INJ USP 1GRAM/4ML J0278 Amikacin sulfate injection THERAPEUTIC INJ HOME HEALTH/INFUSION** FLIPTOP VIAL J0278 AMIKIN Amikacin sulfate injection THERAPEUTIC INJ HOME HEALTH/INFUSION** J0280 AMINOPHYLLINE Aminophyllin 250 MG inj THERAPEUTIC INJ HOME HEALTH/INFUSION** J0282 AMIODARONE HCL Amiodarone hcl THERAPEUTIC INJ C9399, J3490 AMJEVITA Adalimumab-atto injection for subcutaneous use SELF-INJECTABLE J3490 AMONDYS 45™ Casimersen injection, for intravenous use THERAPEUTIC INJ * 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 Rev. April 13, 2021 ** When administered by a nurse in a home setting Page 2 of 39 Effective July 16, 2021 INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY J3470 AMPHADASE 150 UNIT/ML SOLN Hyaluronidase, up to 150 units THERAPEUTIC INJ J0285 AMPHOCIN Amphotericin B THERAPEUTIC INJ HOME HEALTH/INFUSION** J0288 AMPHOTEC Ampho b cholesteryl sulfate THERAPEUTIC INJ HOME HEALTH/INFUSION** J0285 AMPHOTERICIN B Amphotericin B THERAPEUTIC INJ HOME HEALTH/INFUSION** J0290 AMPICILLIN SODIUM Ampicillin 500 MG inj THERAPEUTIC INJ HOME HEALTH/INFUSION** J0295 AMPICILLIN-SULBACTAM Ampicillin sodium per 1.5 gm THERAPEUTIC INJ HOME HEALTH/INFUSION** J0300 AMYTAL SODIUM Amobarbital 125 MG inj THERAPEUTIC INJ J0716 ANASCORP Centruroides immune f(ab)2, up to 120 milligrams THERAPEUTIC INJ J0841 ANAVIP Injection, crotalidae immune f(ab')2 (equine), 120 mg THERAPEUTIC INJ J0690 ANCEF Cefazolin sodium injection THERAPEUTIC INJ HOME HEALTH/INFUSION** Coagulation factor Xa (recombinant), inactivated-zhzo) BLOOD/BLOOD PRODUCTS FOR J7169 ANDEXXA THERAPEUTIC INJ Lyophilized Powder for Solution For Intravenous Injection HEMOPHILIA J0330 ANECTINE Succinycholine chloride inj THERAPEUTIC INJ J0583 ANGIOMAX Bivalirudin, 1mg THERAPEUTIC INJ J1738 ANJESO Meloxicam injection, for intravenous use THERAPEUTIC INJ 90581 ANTHRAX VACCINE Anthrax vaccine, sc THERAPEUTIC INJ IMMUNIZATIONS J1451 ANTIZOL Fomepizole, 15 mg THERAPEUTIC INJ J1260 ANZEMET Dolasetron mesylate THERAPEUTIC INJ CHEMO ADJUNCT* J0364 APOKYN Apomorphine hydrochloride, 1mg SELF-INJECTABLE J3430 AQUA-MEPHYTON Vitamin K phytonadione inj THERAPEUTIC INJ J0256 ARALAST Alpha 1 proteinase inhibitor THERAPEUTIC INJ HOME HEALTH/INFUSION** J0390 ARALEN Chloroquine injection THERAPEUTIC INJ J0380 ARAMINE Metaraminol bitartrate THERAPEUTIC INJ J0881 ARANESP Darbepoetin alfa, 1 microgram (non-ESRD use) SELF-INJECTABLE CHEMO ADJUNCT* J0882 ARANESP Darbepoetin alfa, 1 microgram (for ESRD on dialysis SELF-INJECTABLE CHEMO ADJUNCT* J2793 ARCALYST Rilonacept Injection 220 mg Solr SELF-INJECTABLE J2430 AREDIA Pamidronate disodium /30 MG THERAPEUTIC INJ CHEMO ADJUNCT* J0883 ARGATROBAN Injection, argatroban, 1 mg (for non-ESRD use) THERAPEUTIC INJ J0884 ARGATROBAN Injection, argatroban, 1 mg (for ESRD on dialysis) THERAPEUTIC INJ J9142 ARISTADA Ariprprazole lauroxilextended release suspension THERAPEUTIC INJ Aripiprazole lauroxil extended-release injectable C9035 ARISTADA INITIO THERAPEUTIC INJ suspension J3302 ARISTOCORT FORTE Triamcinolone diacetate inj THERAPEUTIC INJ J3303 ARISTOSPAN INTRA-ARTICULAR Triamcinolone hexacetonl inj THERAPEUTIC INJ J3303 ARISTOSPAN INTRALESIONAL Triamcinolone hexacetonl inj THERAPEUTIC INJ J1652 ARIXTRA Fondaparinux sodium, 0.5 mg SELF-INJECTABLE J9261 ARRANON 5 MG/ML SOLN Nelarabine, 50 Mg THERAPEUTIC INJ CHEMOTHERAPY* J9302 ARZERRA Ofatumumab THERAPEUTIC INJ CHEMOTHERAPY* Injection, immune globulin, intravenous, non-lyophilized J1554 ASCENIV THERAPEUTIC INJ HOME HEALTH/INFUSION** (e.g. liquid), C9399, J3490 ASCLERA Polidocanol Injection THERAPEUTIC INJ * 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 Rev. April 13, 2021 ** When administered by a nurse in a home setting Page 3 of 39 Effective July 16, 2021 INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY
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