inject cd list
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Codes Codes
This section contains a comprehensive list of Medi-Cal reimbursable injection codes. For detailed
injection policy information, refer to the following sections in the appropriate Part 2 provider manual.
· Injections: An Overview
· Injections: Drugs A–D Policy
· Injections: Drugs E–H Policy
· Injections: Drugs I–M Policy
· Injections: Drugs N–R Policy
· Injections: Drugs S–Z Policy
· Injections: Hydration
· Non-Injectable Drugs
Chemotherapy injection policy is located in the Chemotherapy: An Overview, Chemotherapy: Drugs A-D, Chemotherapy: Drugs E-O and Chemotherapy: Drugs P-Z in the appropriate Part 2 manuals.
For a list of the most frequently used vaccines, refer to the Immunizations Code List section in this manual.
2 – Injections: Code List
June 2016
inject cd list
2
Codes Codes
A
Abatacept – 10 mg J0129
AbobotulinumtoxinA – per 5 units J0586
Acetaminophen – 10 mg J0131
Acetazolamide Sodium – up to 500 mg J1120
Acetylcysteine – 100 mg J0132
Acyclovir – 5 mg J0133
Adenosine – 1 mg J0153
Ado-Trastuzumab Emtansine – 1 mg J9354
Adrenalin Epinephrine Injection – 0.1 mg………. J0171
Agalsidase Beta – 1.0 mg J0180
Aldesleukin – per single use vial J9015
Alemtuzumab – 1 mg J0202
Alglucosidase Alfa – 10 mg J0220
Alglucosidase Alfa (Lumizyme) – 10 mg J0221
Alpha 1 Proteinase Inhibitor (human) – 10 mg J0257
Alpha 1 Proteinase Inhibitor (human),
not otherwise specified – 10 mg J0256
Alteplase, recombinant – 1 mg J2997
Amifostine – 500 mg J0207
Amikacin Sulfate – 100 mg J0278
Aminocaproic Acid – 5 gm S0017
Amobarbital – up to 125 mg J0300
Amphotericin B – 50 mg J0285
Amphotericin B cholesteryl sulfate complex – 10 mg J0288
Amphotericin B lipid complex – 10 mg J0287
Amphotericin B liposome – 10 mg J0289
Ampicillin Sodium – 500 mg J0290
Anidulafungin – 1 mg J0348
Argatroban (for ESRD on dialysis) – 1 mg J0884
Argatroban (for non-ESRD use) – 1 mg J0883
Aripiprazole – 0.25 mg J0400
Aripiprazole Extended Release Suspension – 1 mg J0401
Aripiprazole Lauroxil – 1mg J1942
Ascorbic Acid – 500 mg/ml J3490
Ascorbic Acid – 250 mg/ml J3490
Asparaginase – 10,000 units J9020
Asparaginase (erwinaze) – 1,000 IU J9019
Atezolizumab – 10 mg C9483
Atropine Sulfate – 0.01 mg J0461
Avastin – 10 mg J9035
Azacitidine – 1 mg/ml J9025
Azithromycin – 500 mg J0456
2 – Injections: Code List
September 2017
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Codes Codes
B
Bacitracin, intramuscular – 50,000 unit vials J3490
Bacitracin, intramuscular – 10,000 unit vials J3490
Baclofen injection – 10 mg J0475
Baclofen injection, for intrathecal trial – 50 mcg J0476
Basiliximab – 20 mg J0480
BCG vaccine, intravesicular, for bladder cancer 90586
BCG vaccine, percutaneous, for tuberculosis 90585
Belatacept – 1 mg J0485
Belimumab 10 mg J0490
Belinostat – 10 mg J9032
Bendamustine HCl (Bendeka) – 1 mg J9034
Bendamustine HCl (Treanda) – 1 mg J9033
Benztropine Mesylate – 1 mg/ml J0515
Betamethasone Acetate – 3 mg, and
Betamethasone Sodium Phosphate – 3 mg J0702
Bevacizumab – 10 mg J9035
Bezlotoxumab – 10 mg C9490
Bleomycin Sulfate – 15 units J9040
Blinatumomab – 1 mcg J9039
Bortezomib – 0.1 mg J9041
Brentuximab Vedotin – 1mg J9042
Bupivacaine HCl – 30 ml S0020
Bupivacaine Liposome – 1 mg C9290
Butorphanol Tartrate – 1 mg J0595
2 – Injections: Code List
November 2017
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Codes Codes
C
C1 Esterase Inhibitor (human) – 10 units J0598
C1 Esterase Inhibitor (human), Berinert – 10 units J0597
C1 esterase inhibitor (recombinant),
ruconest – 10 units J0596
Cabazitaxel – 1 mg J9043
Caffeine and Sodium Benzoate – 250 mg/ml J3490
Calcitonin Salmon – up to 400 units J0630
Calcitriol – 0.1 mcg J0636
Canakinumab – 1 mg J0638
Cangrelor – 1 mg C9460
Capreomycin Sulfate – 1 gm/5 ml vial J3490
Carbidopa and Levodopa enteral
suspension – 100 ml J7340
Carboplatin – 50 mg J9045
Carfilzomib – 1 mg J9047
Carmustine – 100 mg J9050
Cee-B-Complex – 30 ml J3490
Cefazolin Sodium – 500 mg J0690
Cefotaxime Sodium – per gm J0698
Cefoxitin Sodium – 1 gm J0694
Ceftaroline Fosamil – 10 mg J0712
Ceftazidime and avibactam – 0.5 g/0.125 g J0714
Ceftriaxone Sodium – 250 mg/vial J0696
Centruroides Immune F(AB)2 – up to 120 mg J0716
Certolizumab Pegol – 1 mg J0717
Cetuximab – 10 mg J9055
Chloramphenicol Sodium Succinate – up to 1 gm J0720
Chloroprocaine HCl – per 30 ml J2400
Chlorothiazide Sodium – per 500 mg J1205
Chlorpromazine HCl – up to 50 mg J3230
Chorionic Gonadotropin (HCG) –
per 1,000 USP units J0725
Chromium Cr-51 Sodium Chromate – 250 µCi A9553
Chromium Phosphate P-32 suspension – 1 mCi A9564
Cidofovir – 375 mg J0740
Cisplatin – 10 mg J9060
Clindamycin Phosphate – 300 mg S0077
Clofarabine – 1 mg J9027
Clonidine Hydrochloride – 1 mg/ml J0735
Cobalt Co-57/58, cyanocobalamin – 1 µCi A9546
Cobalt Co-57 cyanocobalamin (oral) – 1 µCi A9559
Collagenase Clostridium Histolyticum – 0.01 mg J0775
Conivaptan hydrochloride – 1 mg C9488
Corticorelin Ovine Triflutate – 1 mcg J0795
Cosyntropin, not otherwise specified – 0.25 mg J0833
Cosyntropin (Cortrosyn) – 0.25 mg J0834
Crotalidae polyvalent immune fab (ovine) –
up to 1 gm J0840
Cyclophosphamide – 100 mg J9070
2 – Injections: Code List
July 2017
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Codes Codes
D
Dacarbazine – 100 mg J9130
Dactinomycin – 0.5 mg J9120
Dalbavancin – 5 mg J0875
Daptomycin – 1 mg J0878
Daratumumab – 10 mg J9145
Darbepoetin Alfa (ESRD) – 1 mcg J0882
Darbepoetin Alfa (non-ESRD) – 1 mcg J0881
Daunorubicin – 10 mg J9150
Decitabine – 1 mg J0894
Deferoxamine Mesylate – 500 mg J0895
Degarelix – 1 mg J9155
Denileukin Diftitox – 300 mcg J9160
Denosumab – 1 mg J0897
Depo-Estradiol Cypionate – up to 5 mg J1000
Dexamethasone Sodium Phosphate – 1 mg J1100
Dexpanthenol – 250 mg/ml J3490
Diazepam – up to 5 mg/ml J3360
Diclofenac Sodium – 0.5 mg J1130
Dicyclomine HCl – up to 20 mg J0500
Digoxin – up to 0.5 mg J1160
Dihydroergotamine Mesylate – 1 mg/ml J1110
Dimercaprol – per 100 mg J0470
Diphenhydramine HCl – up to 50 mg J1200
Diphtheria, Tetanus Toxoid (DT) vaccine –
under 7 years of age 90702
Diphtheria, Tetanus Toxoid and Acellular Pertussis
(DTaP) vaccine, under 7 years of age 90700
Diphtheria, Tetanus Toxoids, Acellular Pertussis
vaccine, and Hepatitis B, and inactivated
Poliovirus vaccine (DtaP-HepB-IPV) 90723
Dobutamine HCl – per 250 mg J1250
Docetaxel – 1 mg J9171
Dolasetron – 10 mg J1260
Dopamine HCl – 40 mg/ml J1265
Dopram – 20 mg/ml J3490
Doripenem – 10 mg J1267
Dornase Alfa – 1 mg J7639
Doxapram HCl – 20 mg/ml J3490
Doxercalciferol – 1 mcg J1270
Doxorubicin HCl – 10 mg J9000
Doxorubicin HCl liposomal, imported Lipodox –
10 mg Q2049
Doxorubicin HCl, liposomal, not otherwise
specified – 10 mg Q2050
Doxycycline – 100 mg (as hyclate)/vial J3490
Droperidol – up to 5 mg J1790
2 – Injections: Code List
September 2017
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Codes Codes
E
Eculizumab – 10 mg J1300
Edrophonium Chloride – 10 mg/ml J3490
Elliott’s B Solution – 1 ml J9175
Elosulfase Alfa – 1 mg J1322
Elotuzumab – 1 mg J9176
Enoxaparin Sodium – 10 mg J1650
Ephedrine Sulfate – 50 mg/ml, 1 ml ampules J3490
Ephedrine Sulfate – 25 mg/ml, 1 ml ampules J3490
Epirubicin HCl – 2 mg J9178
Epoetin Alfa (for ESRD on dialysis) – 100 units Q4081
Epoetin Alfa (for non-ESRD use) – 1000 units J0885
Eribulin Mesylate – 0.1 mg J9179
Erythromycin Lactobionate – per 500 mg J1364
Estradiol Valerate – up to 10 mg J1380
Estrogens Conjugated – per 25 mg J1410
Eteplirsen – 10 mg C9484
Etoposide – 10 mg J9181
F
Fentanyl Citrate – 0.1 mg J3010
Ferric Carboxymaltose – 1 mg J1439
Ferumoxytol (non-ESRD) – 1 mg Q0138
Ferumoxytol (ESRD on dialysis) – 1 mg Q0139
Filgrastim excludes biosimilars – 1 mcg J1442
Filgrastim-sndz – 1 mcg Q5101
Floxuridine – 500 mg J9200
Fludarabine phosphate – 50 mg J9185
Fluorodeoxyglucose – 45 mCi A9552
Fluorouracil – 500 mg J9190
Fluphenazine decanoate – up to 25 mg J2680
Fomepizole – 15 mg J1451
Fosaprepitant – 1 mg J1453
Foscarnet Sodium – 1000 mg J1455
Fulvestrant – 25 mg J9395
Furosemide – up to 20 mg J1940
2 – Injections: Code List
September 2017
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Codes Codes
G
Gadobenate Dimeglumine (MultiHance) – per ml A9577
Gadobenate Dimeglumine (MultiHance multipack) –
per ml A9578
Gadobutrol – 0.1 ml A9585
Gadofosveset Trisodium – 1 ml A9583
Gadolinium, not otherwise specified – per ml A9579
Gadoterate Meglumine – 0.1 ml A9575
Gadoteridol (ProHance multipack) – per ml A9576
Gadoxetate Disodium – per ml A9581
Gallium Ga-67 Citrate – 1 mCi A9556
Galsulfase – 1 mg J1458
Gamma Globulin, intramuscular – over 10 cc J1560
Gamma Globulin, intramuscular – 1 cc J1460
Ganciclovir long-acting implant – 4.5 mg J7310
Gemcitabine – 200 mg J9201
Gentamicin – up to 80 mg J1580
Glucagon HCl – 1 mg J1610
Glucarpidase – 10 units C9293
Glycopyrrolate – 0.2 mg/ml J3490
Gold Sodium Thiomalate – up to 50 mg J1600
Golimumab – 1 mg J1602
Goserelin Acetate Implant – per 3.6 mg J9202
Granisetron, extended release – 0.1 mg C9486
Granisetron HCl – 100 mcg J1626
2 – Injections: Code List
September 2017
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Codes Codes
H
Haemophilus Influenzae b vaccine (Hib) PRP-OMP 90647
Haemophilus Influenzae b vaccine (Hib) PRP-T 90648
Haloperidol – up to 5 mg J1630
Haloperidol Decanoate – 50 mg J1631
Hemin injection – 1 mg J1640
Heparin Sodium – 1,000 units J1644
Heparin Sodium – 10 units J1642
Hepatitis A and Hepatitis B combination vaccine 90636
Hepatitis A vaccine (adult) – 1,440 units/ml 90632
Hepatitis A vaccine (pediatric/adolescent) 90633
Hepatitis B/Haemophilus Influenzae b vaccine 90748
Hepatitis B Immune Globulin – 1 ml 90371
Hepatitis B Immune Globulin (Hepagam B),
intramuscular – 0.5 ml J1571
Hepatitis B Immune Globulin (Hepagam B),
intravenous – 0.5 ml J1573
Hepatitis B vaccine, adolescent (2 dose schedule) 90743
Hepatitis B vaccine, adult dosage 90746
Hepatitis B vaccine, dialysis or
immunosuppressed – per 40 mcg
(3 dose schedule) 90740
Hepatitis B vaccine, dialysis or
Immunosuppressed – per 40 mcg
(4 dose schedule) 90747
Hepatitis B vaccine, pediatric/adolescent
(3 dose schedule) 90744
Histrelin Acetate – 10 mcg J1675
Histrelin Implant (Supprelin LA) – 50 mg J9226
Histrelin Implant (Vantas) – 50 mg J9225
Human Fibrinogen Concentrate – 1 mg J7178
Human Papillomavirus (HPV) vaccine,
intramuscular (9 through 26 years of age) 90649
Human Papillomavirus (HPV) vaccine, types
6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent,
intramuscular, males and females 10 through
25 years of age 90651
Human Papillomavirus (HPV) vaccine,
types 16, 18, bivalent, 3 dose schedule,
intramuscular, females 10 through 25 years of age 90650
Hyalgan – 2 ml J7321
Hyaluronan (Euflexxa) – per dose J7323
Hyaluronan (Monovisc) – per dose J7327
Hyaluronan (Orthovisc) – per dose J7324
Hyaluronan or derivative, gel-syn – 0.1 mg J7328
Hyaluronan or derivative, genvisc 850 – 1 mg J7320
Hyaluronan or derivative, hymovis – 1 mg J7322
Hydralazine HCl – up to 20 mg J0360
Hydrocortisone Sodium Succinate – up to 100 mg J1720
Hydromorphone HCl – up to 4 mg J1170
Hydroxyprogesterone Caproate – 10 mg Q9985
Hydroxyprogesterone Caproate
(Makena) – 10 mg Q9986
2 – Injections: Code List
October 2017
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Codes Codes
I
Ibandronate Sodium – 1 mg J1740
Ibritumomab Tiuxetan (In-111) – 5 mCi A9542
Ibritumomab Tiuxetan (Y-90) – 40 mCi A9543
Ibuprofen – 100 mg J1741
Idursulfase – 1 mg J1743
Ifosfamide – 1 gm J9208
Imiglucerase – 10 units J1786
Immune Globulin (Bivigam) – 500 mg J1556
Immune Globulin (Flebogamma/Flebogamma DIF),
I.V., non-lyophilized (e.g. liquid) – 500 mg J1572
Immune Globulin (Gammagard Liquid), I.V.,
non-lyophilized (e.g. liquid) – 500 mg J1569
Immune Globulin (Gammaplex), I.V.,
non-lyophilized (e.g. liquid) – 500 mg J1557
Immune Globulin, (Gamunex), I.V.,
non-lyophilized (e.g. liquid) – 500 mg J1561
Immune Globulin, (Hizentra) – 100 mg J1559
Immune globulin/hyaluronidase
(hyqvia) – 100 mg J1575
Immune Globulin, I.V., lyophilized (e.g. powder),
not otherwise specified – 500 mg J1566
Immune Globulin, I.V., non-lyophilized (e.g. liquid),
not otherwise specified – 500 mg J1599
Immune Globulin, (Octagam), I.V.,
non-lyophilized (e.g. liquid) – 500 mg J1568
Immune Globulin, (Privigen), I.V.,
non-lyophilized (e.g. liquid) – 500 mg J1459
Immune Globulin, (Vivaglobin) – 100 mg J1562
IncobotulinumtoxinA – 1 unit J0588
Indium In-111 Capromab Pendetide – 10 mCi A9507
Indium In-111 Ibritumomab Tiuxetan – 5 mCi A9542
Indium In-111 Oxyquinoline – 0.5 mCi A9547
Indium In-111 Pentetate – 0.5 mCi A9548
Indium In-111 Pentetreotide – 6 mCi A9572
Infliximab, biosimilar – 10 mg Q5102
Infliximab, excludes biosimilar – 10 mg J1745
Influenza virus vaccine – 0.25 ml 90657
Influenza virus vaccine – 0.5 ml 90658
Influenza virus vaccine, trivalent, split virus,
preservative-free, intradermal, 18 through
64 years of age 90654
Influenza virus vaccine, intramuscular
preservative free – 0.25 ml 90655
Influenza virus vaccine, intramuscular
preservative free – 0.5 ml 90656
Influenza virus vaccine, quadrivalent,
split virus – 0.5 ml 90688
Influenza virus vaccine, quadrivalent, split virus,
preservative free – 0.25 ml 90685
Influenza virus vaccine, quadrivalent, split virus,
preservative free – 0.5 ml 90686
Influenza virus vaccine, quadrivalent, split virus,
preservative free, for intradermal use 90630
Influenza virus vaccine, quadrivalent,
preservative and antibiotic free 90682
Influenza virus vaccine, trivalent, preservative
and antibiotic free, for intramuscular use
(18 to 49 years of age) 90673
Insulin – per 5 units J1815
Interferon Alfa-2b – 1,000,000 units J9214
Interferon Beta-1a – 30 mcg J1826
Iodine I-123 Iobenguane – up to 15 mCi A9582
Iodine Iobenguane Sulfate – 0.5 mCi A9508
Iodine Iodinated Serum Albumin – 5 µCi A9524
Iodine Serum Albumin – 5 µCi A9532
Iodine Sodium Iodide – 1 µCi A9531
Iodine Sodium Iodide capsule(s) – 100 µCi A9516
Iodine Sodium Iodide (diagnostic) – 1 mCi A9528
Iodine Sodium Iodide (therapeutic) – 1 mCi A9517
Iodine Sodium Iothalamate – 10 µCi A9554
Isoproterenol HCl – 1:5,000 sol/1 ml J3490
Irinotecan – 20 mg J9206
Irinotecan liposome – 1 mg J9205
Iron-Based magnetic resonance contrast
agent – 1 ml Q9953
Iron Dextran – 50 mg J1750
Iron Sucrose – 1 mg injection J1756
Ixabepilone – 1 mg J9207
J (no entries)
2 – Injections: Code List
September 2017
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Codes Codes
K
Kanamycin sulfate – up to 500 mg J1840
Ketamine – 100 mg/ml J3490
Ketamine – 50 mg/ml J3490
Ketamine – 10 mg/ml J3490
Ketorolac Tromethamine – 15 mg J1885
L
Lacosamide – 1 mg C9254
Lanreotide Acetate – 1 mg J1930
Laronidase – 0.1 mg J1931
Lepirudin – 50 mg J1945
Leucovorin Calcium – 50 mg J0640
Leuprolide Acetate (for depot suspension) –
per 7.50 mg J9217
Leuprolide Acetate (for depot suspension) –
per 3.75 mg J1950
Levetiracetam – 10 mg J1953
Levoleucovorin Calcium – 0.5 mg J0641
Levothyroxine – 500 mcg/ml J3490
Lidocaine HCl – 10 mg J2001
Lidocaine HCl without preservatives – 4% (40 mg/ml) J2001
Lincomycin HCl– up to 300 mg J2010
Lorazepam – 2 mg J2060
Low osmolar contrast material, 100 – 199 mg/ml
iodine concentration – per ml Q9965
Low osmolar contrast material, 200 – 299 mg/ml
iodine concentration – per ml Q9966
Low osmolar contrast material, 300 – 399 mg/ml
iodine concentration – per ml Q9967
Low osmolar contrast material – 400 mg/ml iodine
or greater concentration – per ml Q9951
2 – Injections: Code List
June 2016