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 J1120 ACETAZOLAMIDE SODIUM Acetazolamide sodium injection THERAPEUTIC INJ J0132 ACETYLCYSTEINE INJ Acetylcysteine injection, 10 mg THERAPEUTIC INJ ACTEMRA 162mg/0.9ml Syringe (50242- J3262 SELF-INJECTABLE 0138-01) Tocilizumab, 1 mg ACTEMRA INJECTION (50242-0136-01, J3262 50242-0137-01) Tocilizumab 200mg, 400mg THERAPEUTIC INJ J0800 ACTHAR HP Corticotropin injection THERAPEUTIC INJ Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4- 90648 ACTHIB dose schedule), for intramuscular use THERAPEUTIC INJ IMMUNIZATIONS 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** J9042 ADCETRIS Brentuximab vedotin Injection THERAPEUTIC INJ CHEMOTHERAPY J0153 ADENOCARD Adenosine 6 MG THERAPEUTIC INJ 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 otherwise specified THERAPEUTIC INJ HEMOPHILIA Antihemophilic Factor (Recombinant), PEGylated, is a BLOOD/BLOOD PRODUCTS FOR ADYNOVATE THERAPEUTIC INJ C9137 human antihemophilic factor HEMOPHILIA Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for 90656 AFLURIA PRESERVATIVE FREE SUSP intramuscular use (Code Price is per 0.5 mL dose) (Please note: Agriflu is only indicated for use in patients 18 years of age and older) THERAPEUTIC INJ IMMUNIZATIONS Influenza virus vaccine, split virus, when administered to 90658 AFLURIA SUSP individuals 3 years of age and older, for intramuscular use (Code price is per 0.5 mL based on Fluzone for patients 3 through 17 years old) (For patients 18 years old and older. THERAPEUTIC INJ IMMUNIZATIONS Influenza virus vaccine, split virus, when administered to Q2035 AFLURIA SUSP individuals 3 years of age and older, for intramuscular use (Afluria) see also 90656 and 90658 THERAPEUTIC INJ IMMUNIZATIONS BLOOD/BLOOD PRODUCTS FOR Factor VIII (antihemophilic factor, recombinant, single chain) THERAPEUTIC INJ J7199 AFSTYLA 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* J0190 AKINETON Biperiden lactate, per 5 mg THERAPEUTIC INJ J1931 ALDURAZYME Laronidase injection THERAPEUTIC INJ HOME HEALTH/INFUSION** J9215 ALFERON N Interferon alfa-N3 (human leukocyte derived), 250,000 IU inj SELF-INJECTABLE CHEMO ADJUNCT* * If associated with a cancer Dx ICD‐9 Rev.7/12/16 ** When administered by a nurse in a home setting 1 of 28 Effective 10/18/16 INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY J9305 ALIMTA Pemetrexed, 10 mg 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 coFactor BLOOD/BLOOD PRODUCTS FOR J7186 ALPHANATE VWF (not otherwise specified ), per I.U. THERAPEUTIC INJ HEMOPHILIA Factor IX (antihemophilic Factor, purified, non-recombinant) BLOOD/BLOOD PRODUCTS FOR J7193 ALPHANINE SD per IU THERAPEUTIC INJ 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 supervision, not for use when drug is self-administered) SELF-INJECTABLE 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 FLIPTOP VIAL Amikacin sulfate injection THERAPEUTIC INJ HOME HEALTH/INFUSION** 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 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 J0690 ANCEF Cefazolin sodium injection THERAPEUTIC INJ HOME HEALTH/INFUSION** J0330 ANECTINE Succinycholine chloride inj THERAPEUTIC INJ J0583 ANGIOMAX Bivalirudin, 1mg 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* C9121 ARGATROBAN 100 MG/ML SOLN Argatroban, Per 5 mg THERAPEUTIC INJ C9138 ARISTADA Ariprprazole lauroxilextended release suspension THERAPEUTIC INJ J3302 ARISTOCORT FORTE Triamcinolone diacetate inj THERAPEUTIC INJ * If associated with a cancer Dx ICD‐9 Rev.7/12/16 ** When administered by a nurse in a home setting 2 of 28 Effective 10/18/16 INJECTABLE MEDICATION HCPCS/DOFR CROSSWALK HCPCS DRUG NAME GENERIC NAME PRIMARY CATEGORY SECONDARY CATEGORY 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 C9399, J3490 ASCLERA Polidocanol Injection THERAPEUTIC INJ J2275 ASTRAMORPH Morphine sulfate injection THERAPEUTIC INJ HOME HEALTH/INFUSION** Lymphocyte immune globulin, antithymocyte globulin, J7504 ATGAM equine, parenteral, 250 mg THERAPEUTIC INJ HOME HEALTH/INFUSION** J2060 ATIVAN Lorazepam injection THERAPEUTIC INJ J0461 ATROPINE SULFATE Atropine sulfate injection THERAPEUTIC INJ Antithrombin (Recombinant) BLOOD/BLOOD PRODUCTS FOR J7196 ATRYN Lyophilized THERAPEUTIC INJ HEMOPHILIA 90705 ATTENUVAX Measles vaccine, SC THERAPEUTIC INJ IMMUNIZATIONS C9257 AVASTIN Bevacizumab, 0.25 mg THERAPEUTIC INJ CHEMOTHERAPY J9035 AVASTIN Bevacizumab injection, 10 mg THERAPEUTIC INJ CHEMOTHERAPY J3145 AVEED Testosterone undecanoate 250 mg/ml THERAPEUTIC INJ J2280 AVELOX Moxifloxacin 100 mg THERAPEUTIC INJ HOME HEALTH/INFUSION** Interferon beta-1A, 11 mcg for intramuscular use (See also Q3025 AVONEX J1825) SELF-INJECTABLE Q3027 AVONEX Interferon beta-1a, 33 mcg SELF-INJECTABLE J0714 AVYCAZ Ceftazidime-avibactam Injection THERAPEUTIC INJ S0073 AZACTAM Aztreonam, 500 mg THERAPEUTIC INJ HOME HEALTH/INFUSION** J7501 AZATHIOPRINE SODIUM Azathioprine parenteral THERAPEUTIC INJ TRANSPLANT* J0475 BACLOFEN Baclofen 10 MG injection THERAPEUTIC INJ J2700 BACTOCILL IN DEXTROSE Oxacillin sodium injeciton THERAPEUTIC INJ HOME HEALTH/INFUSION** J0470 BAL IN OIL Dimecaprol injection THERAPEUTIC INJ Hepatitis B Immune Globulin (HBIg), human, for 90371 BAYHEP B intramuscular use (Note: For billing HepaGam B use Q4090 for IM use and 90399 for IV use) THERAPEUTIC INJ Rabies Immune Globulin (R IG), human, for intramuscular 90375 BAYRAB and/or subcutaneous use THERAPEUTIC INJ 90385 BAYRHO-D Rh IG, minidose, IM THERAPEUTIC INJ J2788 BAYRHO-D Rho d immune globulin, human, minidose, 50 mcg (250 iu) THERAPEUTIC INJ J2790 BAYRHO-D Rho d immune globulin, human, minidose, 300 mcg (1500 iu) THERAPEUTIC