HAMP - Health Alliance Medical Plan – Commercial

HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial 5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary

Ado- 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

Page 1 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial Cladribine Leustatin J9065 Y INJECTABLE Primary

Clofarabine Clolar J9027 Y INJECTABLE Primary

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

Page 2 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary

Interferon, alfa-n3 Alferon N J9215 Y INJECTABLE Primary

Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary

Ipilumumab Yervoy J9228 Y INJECTABLE Primary

Irinotecan Camptosar J9206 Y INJECTABLE Primary

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

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

Page 3 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial 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

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

Page 4 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial 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) 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

Abemaciclib - oral Verzenio C9399 Y ORAL Primary

Abemaciclib - oral Verzenio J8999 Y ORAL Primary

Abiraterone Acetate - oral Zytiga (not interchangeable with Yonsa) J8999 Y ORAL Primary

Abiraterone Acetate - oral (Not Yonsa (not interchangeable with Zytiga) J8999 Y ORAL Primary currently on the market) Calquence C9399 Y ORAL Primary

Acalabrutinib Calquence J8999 Y ORAL Primary

Afatinib - oral Gilotrif J8999 Y ORAL Primary

Alectinib - oral Alecensa J8999 Y ORAL Primary

All-trans Retinoic Acid - oral Vesanoid, ATRA, Tretinoin J8999 Y ORAL Primary

Altretamine - oral Hexalen J8999 Y ORAL Primary

Apalutamide - oral Erleada J8999 Y ORAL Primary

Axitinib - oral Inlyta J8999 Y ORAL Primary

Page 5 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial Bexarotene - oral Targretin J8999 Y ORAL Primary

Binimetinib - oral Mektovi J8999 Y ORAL Primary

Bosutinib - oral Bosulif J8999 Y ORAL Primary

Brigatinib - oral Alunbrig J8999 Y ORAL Primary

Cabozantinib - oral Cabometyx J8999 Y ORAL Primary

Cabozantinib - oral Cometriq J8999 Y ORAL Primary

Capecitabine - oral Xeloda (150 mg) J8520 Y ORAL Primary

Capecitabine - oral Xeloda (500 mg) J8521 Y ORAL Primary

Ceritinib - oral Zykadia J8999 Y ORAL Primary

Chlorambucil - oral Leukeran J8999 Y ORAL Primary

Chlorambucil - oral Leukeran S0172 Y ORAL Primary

Cobimetinib - oral Cotellic J8999 Y ORAL Primary

Crizotinib - oral Xalkori J8999 Y ORAL Primary

Cyclophosphamide - oral Cytoxan J8530 Y ORAL Primary

Dabrafenib - oral Tafinlar J8999 Y ORAL Primary

Dacomitinib - oral Vizimpro J8999 Y ORAL Primary

Dasatinib - oral Sprycel J8999 Y ORAL Primary

Duvelisib - oral Copiktra J8999 Y ORAL Primary

Enasidenib - oral IDHIFA J8999 Y ORAL Primary

Encorafenib - oral Braftovi J8999 Y ORAL Primary

Enzalutamide - oral Xtandi J8999 Y ORAL Primary

Erdafitinib Balversa J8999 Y ORAL Primary

Erlotinib - oral Tarceva J8999 Y ORAL Primary

Estramustine - oral Emcyt J8999 Y ORAL Primary

Etoposide - oral Toposar J8560 Y ORAL Primary

Everolimus - oral Afinitor J8999 Y ORAL Primary

Flutamide - oral Eulexin J8999 Y ORAL Primary

Gefitinib - oral Iressa J8565 Y ORAL Primary

Gilteritinib - oral Xospata J8999 Y ORAL Primary

Glasdegib - oral Daurismo J8999 Y ORAL Primary

Ibrutinib - oral Imbruvica J8999 Y ORAL Primary

Idelalisib - oral Zydelig J8999 Y ORAL Primary

Imatinib - oral Gleevec J8999 Y ORAL Primary

Imatinib - oral Gleevec S0088 Y ORAL Primary

Ivosidenib - oral Tibsovo J8999 Y ORAL Primary

Ixazomib - oral Ninlaro J8999 Y ORAL Primary

Page 6 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial - oral Tykerb J8999 Y ORAL Primary

Larotrectinib - oral Vitrakvi J8999 Y ORAL Primary

Lenalidomide - oral Revlimid J8999 Y ORAL Primary

Lenvatinib - oral Lenvima J8999 Y ORAL Primary

Lomustine - oral Gleostine, CeeNu, CCNU S0178 Y ORAL Primary

Lorlatinib - oral Lorbrena C9399 Y ORAL Primary

Lorlatinib - oral Lorbrena J8999 Y ORAL Primary

Melphalan - oral Alkeran J8600 Y ORAL Primary

Midostaurin - oral Rydapt J8999 Y ORAL Primary

Mitotane - oral Lysodren J8999 Y ORAL Primary

Neratinib - oral Nerlynx J8999 Y ORAL Primary

Nilotinib - oral Tasigna J8999 Y ORAL Primary

Niraparib - oral Zejula J8999 Y ORAL Primary

Olaparib - oral Lynparza J8999 Y ORAL Primary

Osimertinib - oral Tagrisso J8999 Y ORAL Primary

Palbociclib - oral Ibrance J8999 Y ORAL Primary

Panobinostat - oral Farydak J8999 Y ORAL Primary

Pazopanib - oral Votrient J8999 Y ORAL Primary

Pomalidomide - oral Pomalyst J8999 Y ORAL Primary

Ponatinib - oral Iclusig J8999 Y ORAL Primary

Procarbazine - oral Matulane J8999 Y ORAL Primary

Procarbazine - oral Matulane S0182 Y ORAL Primary

Regorafenib - oral Stivarga J8999 Y ORAL Primary

Ribociclib - oral Kisqali J8999 Y ORAL Primary

Rucaparib - oral Rubraca J8999 Y ORAL Primary

Ruxolitinib - oral Jakafi J8999 Y ORAL Primary

Sonidegib - oral Odomzo J8999 Y ORAL Primary

Sorafenib Tosylate - oral Nexavar J8999 Y ORAL Primary

Sunitinib - oral Sutent J8999 Y ORAL Primary

Talazoparib - oral Talzenna J8999 Y ORAL Primary

Temozolomide - oral Temodar J8700 Y ORAL Primary

Thalidomide - oral Thalomid J8999 Y ORAL Primary

Topotecan - oral Hycamtin J8705 Y ORAL Primary

Toremifene Citrate - oral Fareston J8999 Y ORAL Primary

Trametinib - oral Mekinist J8999 Y ORAL Primary

Trifluridine/Tipiracil - oral Lonsurf J8999 Y ORAL Primary

Page 7 of 8 HAMP - Health Alliance Primary Alt Descriptions HCPCS Codes Medical Plan - Administration Technique Drug Class Commercial Valganciclovir - oral Valcyte J8499 Y ORAL Primary

Vandetanib - oral Caprelsa J8999 Y ORAL Primary

Vemurafenib - oral Zelboraf J8999 Y ORAL Primary

Venetoclax - oral Venclexta J8999 Y ORAL Primary

Vismodegib - oral Erivedge J8999 Y ORAL Primary

Vorinostat - oral Zolinza J8999 Y ORAL Primary

Bexarotene - topical Targretin gel C9399 Y TOPICAL Primary

Bexarotene - topical Targretin gel J3490 Y TOPICAL Primary

Mechlorethamine - topical Valchlor J9999 Y TOPICAL Primary

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

Octreotide depot Sandostatin J2353 Y INJECTABLE Supportive

Octreotide non-depot Sandostatin J2354 Y INJECTABLE Supportive

Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive

Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive

Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive

Sargramostim Leukine J2820 Y INJECTABLE Supportive

Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive

Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive

Cabergoline - oral Dostinex J8515 Y ORAL Supportive

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