Oncology and Chemo-Support Drug List Drug name HCPCS Code Requirements 5-Fluorouracil J9190 - Ado-Trastuzumab Emtansine J9354 PA Aldesleukin J9015 PA Aprepitant - inj J0185 PA Aprepitant - oral J8501 - Arsenic Trioxide J9017 - Asparaginase J9019 - Atezolizumab J9022 PA Avelumab J9023 PA Azacitidine J9025 - BCG J9030 PA Belinostat J9032 PA Bendamustine (TREANDA) J9033 - Bendamustine (BENDEKA) J9034 PA Bendamustine HCL J9036 PA Bevacizumab - Opthalmic Use J9035 - Bevacizumab J9035 PA Bevacizumab-awwb Q5107 PA Bleomycin J9040 - Blinatumomab J9039 PA Bortezomib J9041 PA Bortezomib, not otherwise specified J9044 PA Brentuximab Vedotin J9042 PA Cabazitaxel J9043 - Calaspargase pegol-mknl J9118 PA Capecitabine 150 mg J8520 PA
Capecitabine 500 mg J8521 PA Carboplatin J9045 - Carfilzomib J9047 PA Carmustine J9050 - Cemiplimab-rwlc J9119 PA Cetuximab J9055 - Cisplatin J9060 - Cladribine J9065 - Clofarabine J9027 PA Copanlisib J9057 PA Cyclophosphamide J9070 -
Effective 7/1/2021 Cytarabine J9100 - Cytarabine Liposome J9098 PA Dacarbazine J9130 - Dactinomycin J9120 PA Daratumumab J9145 PA Darbepoetin alfa J0881 PA Daunorubicin J9150 - Decitabine J0894 - Degarelix J9155 PA Denosumab J0897 PA Docetaxel J9171 - Doxorubicin HCL J9000 - Doxorubicin HCL liposomal (Lipodox) Q2049 PA Doxorubicin HCL liposomal (not otherwise Q2050 PA specified) Durvalumab J9173 PA Elotuzumab J9176 PA Epirubicin J9178 - Epoetin alfa J0885 PA Epoetin alfa-epbx Q5106 PA Eribulin mesylate J9179 PA Etoposide - inj J9181 - Etoposide - oral J8560 - Everolimus J7527 PA Ferumoxytol (non-ESRD use) Q0138 - Ferumoxytol (ESRD on dialysis) Q0139 - Filgrastim J1442 PA Filgrastim-aafi Q5110 - Filgrastim-sndz Q5101 PA Floxuridine J9200 - Fludarabine Phosphate J9185 - Fluoxymesterone J8499 PA Fosaprepitant J1453 PA Fulvestrant J9395 PA Gefitinib J8565 PA Gemcitabine J9201 - Gemcitabine HCL - NACL J9198 - Gemtuzumab Ozogamicin J9203 PA Goserelin acetate implant J9202 PA Granisetron J1627 PA
Effective 7/1/2021 Histrelin Implant (VANTAS) J9225 PA Histrelin Implant (SUPPRELIN LA) J9226 PA Idarubicin HCL J9211 - Ifosfamide J9208 - Inotuzumab Ozogamicin J9229 PA Interferon, alfa-2b, recombinant J9214 PA Interferon, gamma-1b J9216 PA Ipilumumab J9228 PA Irinotecan J9206 - Irinotecan Liposome J9205 - Ixabepilone J9207 - Lanreotide J1930 PA Leucovorin - inj J0640 - Leuprolide Acetate (for depot suspension), 3.75 mg J1950 PA Leuprolide Acetate (for depot suspension), 7.5 mg J9217 PA Leuprolide Acetate, 1 mg J9218 PA Levoleucovorin J0642 PA Levoleucovorin, not otherwise specified, 0.5 mg J0641 - Liposome-encapsulated combination of J9153 PA Daunorubicin and Cytarabine Lomustine S0178 - Mechlorethamine HCL J9230 PA Melphalan HCL J9245 PA Mesna J9209 - Methotrexate Sodium 5mg J9250 - Methotrexate Sodium 50mg J9260 - Mitomycin J9280 - Mitoxantrone HCL J9293 - Mogamulizumab-kpkc J9204 PA Moxetumomab pasudotox-tdfk J9313 PA Necitumumab J9295 - Nelarabine J9261 PA Netupitant/Palonosetron J8655 PA Nivolumab J9299 PA Obinutuzumab J9301 PA Octreotide depot J2353 PA Octreotide non-depot J2354 - Ofatumumab J9302 - Olaratumab J9285 PA Omacetaxine J9262 PA
Effective 7/1/2021 Oxaliplatin J9263 - Paclitaxel J9267 - Paclitaxel (albumin-bound) J9264 - Palonosetron J2469 PA Pamidronate Disodium J2430 PA Panitumumab J9303 PA Pegaspargase J9266 PA Pegfilgrastim J2505 PA Pegfilgrastim-cbqv Q5111 PA Pegfilgrastim-jmdb Q5108 - Peginterferon, alfa-2a J3590 PA Pembrolizumab J9271 PA Pemetrexed J9305 PA Pentostatin J9268 PA Pertuzumab J9306 PA Porfimer Sodium J9600 PA Pralatrexate J9307 PA Ramucirumab J9308 PA Rituximab and Hyaluronidase Human J9311 PA Rituximab J9312 PA Rituximab -pvvr Q5119 PA Rituximab-abbs Q5115 PA Rolapitant J8670 PA Romidepsin J9315 PA Sargramostim J2820 PA Siltuximab J2860 PA Sipuleucel-T Q2043 PA Streptozocin J9320 PA Tagraxofusp-erzs J9269 PA Talimogene Laherparepvec J9325 - Tbo-filgrastim J1447 PA Temozolomide - inj J9328 PA Temozolomide - oral J8700 PA Temsirolimus J9330 - Teniposide Q2017 - Thiotepa J9340 PA Tocilizumab J3262 PA Topotecan - inj J9351 - Topotecan- oral J8705 -
Effective 7/1/2021 Trabectedin J9352 - Trastuzumab and hyaluronidase-oysk J9356 PA Trastuzumab J9355 PA Trastuzumab-anns Q5117 PA Trastuzumab-dkst Q5114 PA Trastuzumab-dttb Q5112 PA Trastuzumab-pkrb Q5113 PA Trastuzumab-qyyp Q5116 PA Triptorelin Pamoate J3315 PA Valrubicin J9357 PA Vinblastine Sulfate J9360 - Vincristine Sulfate J9370 - Vincristine Sulfate Liposome J9371 PA Vinorelbine Tartrate J9390 - Zivafibercept J9400 PA Zoledronic Acid J3489 PA Unclassified J3490 PA Unclassified J3590 PA
Effective 7/1/2021