BCBSMN Medicare

Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class 5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary

Ado-Trastuzumab Emtansine Kadcyla J9354 Y INJECTABLE Primary

Aldesleukin Proleukin, Interleukin-2 J9015 Y INJECTABLE Primary

Arsenic Trioxide Trisenox J9017 Y INJECTABLE Primary

Asparaginase Erwinaze J9019 Y INJECTABLE Primary

Atezolizumab Tecentriq J9022 Y INJECTABLE Primary

Avelumab Bavencio J9023 Y INJECTABLE Primary

Azacitidine Vidaza J9025 Y INJECTABLE Primary

BCG TheraCys, Tice J9031 Y INJECTABLE Primary

Belinostat Beleodaq J9032 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) C9399 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary

Bendamustine Treanda J9033 Y INJECTABLE Primary

Bendamustine HCL Belrapzo C9042 Y INJECTABLE Primary

Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary

Bevacizumab Avastin J9035 Y INJECTABLE Primary

Bevacizumab-awwb (not currently Mvasi Q5107 Y INJECTABLE Primary available on the market) Bleomycin Blenoxane J9040 Y INJECTABLE Primary

Blinatumomab Blincyto J9039 Y INJECTABLE Primary

Bortezomib Velcade J9041 Y INJECTABLE Primary

Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary

Brentuximab Vedotin Adcetris J9042 Y INJECTABLE Primary

Cabazitaxel Jevtana J9043 Y INJECTABLE Primary

Calaspargase pegol-mknl Asparlas J3490 Y INJECTABLE Primary

Calaspargase pegol-mknl Asparlas J3590 Y INJECTABLE Primary

Carboplatin Paraplatin J9045 Y INJECTABLE Primary

Carfilzomib Kyprolis J9047 Y INJECTABLE Primary

Carmustine BiCNU, BCNU J9050 Y INJECTABLE Primary

Cemiplimab-rwlc Libtayo C9399 Y INJECTABLE Primary

Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary

Cemiplimab-rwlc Libtayo C9044 Y INJECTABLE Primary

Cetuximab Erbitux J9055 Y INJECTABLE Primary

Cisplatin Platinol J9060 Y INJECTABLE Primary

Cladribine Leustatin J9065 Y INJECTABLE Primary

Clofarabine Clolar J9027 Y INJECTABLE Primary

Page 1 of 6 Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class Copanlisib Aliqopa J9057 Y INJECTABLE Primary

Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Y INJECTABLE Primary

Cytarabine Ara-C J9100 Y INJECTABLE Primary

Cytarabine-Liposome DepoCyt J9098 Y INJECTABLE Primary

Dacarbazine DTIC-Dome J9130 Y INJECTABLE Primary

Dactinomycin Cosmegen, Actinomycin J9120 Y INJECTABLE Primary

Daratumumab Darzalex J9145 Y INJECTABLE Primary

Daunorubicin Cerubidine J9150 Y INJECTABLE Primary

Decitabine Dacogen J0894 Y INJECTABLE Primary

Degarelix Firmagon J9155 Y INJECTABLE Primary

Denosumab Xgeva, Prolia J0897 Y INJECTABLE Primary

Dinutuximab Unituxin C9399 Y INJECTABLE Primary

Dinutuximab Unituxin J9999 Y INJECTABLE Primary

Docetaxel Taxotere J9171 Y INJECTABLE Primary

Doxorubicin HCL Adriamycin J9000 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Lipodox Q2049 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Doxil Q2050 Y INJECTABLE Primary

Durvalumab Imfinzi J9173 Y INJECTABLE Primary

Elotuzumab Empliciti J9176 Y INJECTABLE Primary

Epirubicin Ellence J9178 Y INJECTABLE Primary

Eribulin mesylate Halaven J9179 Y INJECTABLE Primary

Etoposide - inj Toposar, VePesid, Etopophos J9181 Y INJECTABLE Primary

Floxuridine FUDR J9200 Y INJECTABLE Primary

Fludarabine Phosphate Fludara, Oforta J9185 Y INJECTABLE Primary

Fulvestrant Faslodex J9395 Y INJECTABLE Primary

Gemcitabine Gemzar J9201 Y INJECTABLE Primary

Gemcitabine HCL - NACL Infugem J3490 Y INJECTABLE Primary

Gemcitabine HCL - NACL Infugem J9999 Y INJECTABLE Primary

Gemtuzumab Ozogamicin Mylotarg J9203 Y INJECTABLE Primary

Goserelin acetate implant Zoladex J9202 Y INJECTABLE Primary

Histrelin Implant Vantas J9225 Y INJECTABLE Primary

Idarubicin HCL - inj Idamycin J9211 Y INJECTABLE Primary

Ifosfamide Ifex, Mitoxana J9208 Y INJECTABLE Primary

Inotuzumab Ozogamicin Besponsa J9229 Y INJECTABLE Primary

Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary

Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary

Ipilumumab Yervoy J9228 Y INJECTABLE Primary

Irinotecan Camptosar J9206 Y INJECTABLE Primary

Page 2 of 6 Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary

Ixabepilone Ixempra J9207 Y INJECTABLE Primary

Lanreotide Somatuline Depot J1930 Y INJECTABLE Primary

Leucovorin - inj Leucovorin J0640 Y INJECTABLE Primary

Leuprolide Acetate Eligard, Lupron Depot, Lupron, J1950 Y INJECTABLE Primary Leuprolide Acetate Leuprolide Acetate Eligard, Lupron Depot, Lupron, J9217 Y INJECTABLE Primary Leuprolide Acetate Leuprolide Acetate Eligard, Lupron Depot, Lupron, J9218 Y INJECTABLE Primary Leuprolide Acetate Levoleucovorin Fusilev J0641 Y INJECTABLE Primary

Levoleucovorin Khapzory J3490 Y INJECTABLE Primary

Levoleucovorin Khapzory C9399 Y INJECTABLE Primary

Levoleucovorin Khapzory C9043 Y INJECTABLE Primary

Liposome-encapsulated Vyxeos J9153 Y INJECTABLE Primary combination of Daunorubicin and Cytarabine Mechlorethamine HCL Mustragen J9230 Y INJECTABLE Primary

Melphalan HCL - inj Alkeran J9245 Y INJECTABLE Primary

Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Y INJECTABLE Primary

Methotrexate Sodium (J9260: Folex, Methotrexate J9260 Y INJECTABLE Primary 50mg) Mitomycin Mutamycin J9280 Y INJECTABLE Primary

Mitoxantrone HCL Novantrone J9293 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti J9999 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti C9045 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo J9999 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo C9038 Y INJECTABLE Primary

Necitumumab Portrazza J9295 Y INJECTABLE Primary

Nelarabine Arranon J9261 Y INJECTABLE Primary

Nivolumab Opdivo J9299 Y INJECTABLE Primary

Obinutuzumab Gazyva J9301 Y INJECTABLE Primary

Octreotide depot Sandostatin J2353 Y INJECTABLE Primary

Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary

Ofatumumab Arzerra J9302 Y INJECTABLE Primary

Olaratumab Lartruvo J9285 Y INJECTABLE Primary

Omacetaxine Synribo J9262 Y INJECTABLE Primary

Oxaliplatin Eloxatin J9263 Y INJECTABLE Primary

Paclitaxel Nov-Onxol, Taxol J9267 Y INJECTABLE Primary

Paclitaxel (albumin-bound) Abraxane J9264 Y INJECTABLE Primary

Panitumumab Vectibix J9303 Y INJECTABLE Primary

Page 3 of 6 Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class Pegaspargase Oncaspar J9266 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys S0145 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron J3590 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron S0148 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron C9399 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron J9999 Y INJECTABLE Primary

Pembrolizumab Keytruda J9271 Y INJECTABLE Primary

Pemetrexed Alimta J9305 Y INJECTABLE Primary

Pentostatin Nipent J9268 Y INJECTABLE Primary

Pertuzumab Perjeta J9306 Y INJECTABLE Primary

Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary

Pralatrexate Folotyn J9307 Y INJECTABLE Primary

Ramucirumab Cyramza J9308 Y INJECTABLE Primary

Rituximab Rituxan J9312 Y INJECTABLE Primary

Rituximab-abbs Truxima C9399 Y INJECTABLE Primary

Rituximab-abbs Truxima J3490 Y INJECTABLE Primary

Rituximab-abbs Truxima J3590 Y INJECTABLE Primary

Rituximab-abbs Truxima J9999 Y INJECTABLE Primary

Rituximab and Hyaluronidase Rituxan Hycela J9311 Y INJECTABLE Primary Human Romidepsin Istodax J9315 Y INJECTABLE Primary

Siltuximab Sylvant J2860 Y INJECTABLE Primary

Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary

Streptozocin Zanosar J9320 Y INJECTABLE Primary

Tagraxofusp-erzs (not available to Elzonris C9399 Y INJECTABLE Primary market yet) Tagraxofusp-erzs (not available to Elzonris J9999 Y INJECTABLE Primary market yet) Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary

Temozolomide - inj Temodar J9328 Y INJECTABLE Primary

Temsirolimus Torisel J9330 Y INJECTABLE Primary

Teniposide Vumon Q2017 Y INJECTABLE Primary

Thiotepa Thioplex J9340 Y INJECTABLE Primary

Tocilizumab Actemra J3262 Y INJECTABLE Primary

Topotecan - inj Hycamtin J9351 Y INJECTABLE Primary

Trabectedin Yondelis J9352 Y INJECTABLE Primary

Trastuzumab Herceptin J9355 Y INJECTABLE Primary

Trastuzumab-dkst (Not currently on Ogiviri J3490 Y INJECTABLE Primary the Market)

Page 4 of 6 Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class Trastuzumab-dkst (Not currently on Ogiviri J3590 Y INJECTABLE Primary the Market) Trastuzumab-dkst (Not currently on Ogiviri J9999 Y INJECTABLE Primary the Market) Trastuzumab-dttb (Not currently on Ontruzant J3490 Y INJECTABLE Primary the Market) Trastuzumab-dttb (Not currently on Ontruzant J3590 Y INJECTABLE Primary the Market) Trastuzumab-pkrb Herzuma J3490 Y INJECTABLE Primary

Trastuzumab-pkrb Herzuma J3590 Y INJECTABLE Primary

Trastuzumab-qyyp Trazimera J3490 Y INJECTABLE Primary

Trastuzumab-qyyp Trazimera J3590 Y INJECTABLE Primary

Trastuzumab and hyaluronidase- Herceptin Hylecta J3490 Y INJECTABLE Primary oysk Trastuzumab and hyaluronidase- Herceptin Hylecta J3590 Y INJECTABLE Primary oysk Triptorelin Pamoate Trelstar J3315 Y INJECTABLE Primary

Valrubicin Valstar J9357 Y INJECTABLE Primary

Vinblastine Sulfate Velban J9360 Y INJECTABLE Primary

Vincristine Sulfate Oncovin, Vincasar PFS J9370 Y INJECTABLE Primary

Vincristine Sulfate Liposome Marqibo J9371 Y INJECTABLE Primary

Vinorelbine Tartrate Navelbine J9390 Y INJECTABLE Primary

Zivafibercept Zaltrap J9400 Y INJECTABLE Primary

Aprepitant Cinvanti J0185 Y INJECTABLE Supportive/Antiemetic

Darbepoetin alfa Aranesp J0881 Y INJECTABLE Supportive

Denosumab Xgeva, Prolia J0897 Y INJECTABLE Supportive

Epoetin alfa Epogen, Procrit J0885 Y INJECTABLE Supportive

Epoetin alfa-epbx Retacrit Q5106 Y INJECTABLE Supportive

Filgrastim Neupogen J1442 Y INJECTABLE Supportive

Filgrastim-aafi Nivestym Q5110 Y INJECTABLE Supportive

Filgrastim-sndz Zarxio Q5101 Y INJECTABLE Supportive

Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic

Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic

Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive

Fosnetupitant/Palonosetron Akynzeo J1454 Y INJECTABLE Supportive/Antiemetic

Octreotide depot Sandostatin J2353 Y INJECTABLE Supportive

Octreotide non-depot Sandostatin J2354 Y INJECTABLE Supportive

Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic

Pamidronate Disodium Aredia J2430 Y INJECTABLE Supportive

Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive

Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive

Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive

Page 5 of 6 Primary Alt Descriptions HCPCS Codes BCBSMN: Medicare Administration Technique Drug Class Sargramostim Leukine J2820 Y INJECTABLE Supportive

Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive

Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive

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