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Health Partners Plan - Medical Oncology List

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Health Partners Plan - Medical Oncology List Health Partners Plan - Medical Oncology List Primary Alt Descriptions HCPCS Codes HPP 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 Exported on April 26, 2019 11:24:57 AM EDT Page 1 of 5 Primary Alt Descriptions HCPCS Codes HPP 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 Ipilumumab Yervoy J9228 Y INJECTABLE Primary Irinotecan Camptosar J9206 Y INJECTABLE Primary Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary Exported on April 26, 2019 11:24:57 AM EDT Page 2 of 5 Primary Alt Descriptions HCPCS Codes HPP Administration Technique Drug Class 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 Pegaspargase Oncaspar J9266 Y INJECTABLE Primary Exported on April 26, 2019 11:24:57 AM EDT Page 3 of 5 Primary Alt Descriptions HCPCS Codes HPP Administration Technique Drug Class Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary Peginterferon, alfa-2b PegIntron J3590 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) Trastuzumab-dkst (Not currently on Ogiviri J3590 Y INJECTABLE Primary the Market) Trastuzumab-dkst (Not currently on Ogiviri J9999 Y INJECTABLE Primary the Market) Exported on April 26, 2019 11:24:57 AM EDT Page 4 of 5 Primary Alt Descriptions HCPCS Codes HPP Administration Technique Drug Class 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
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