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HPHC Chemotherapy HCPCS J-Codes List– Prior Authorization

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HPHC Chemotherapy HCPCS J-Codes List– Prior Authorization HPHC Chemotherapy HCPCS J-Codes List– Prior Authorization Required Copyright © 2020 Oncology Analytics, Inc. All rights reserved. HCPCS Hcpcs Description Generic Name Latest Label Name J9999 Peginterferon Alfa-2b SYLATRON 888 MCG 4-PACK Ado-Trastuzumab Emt Inj, J9354 1 MG Ado-Trastuzumab Emtansine KADCYLA 160 MG VIAL J9015 Aldesleukin Inj, 1 EA Aldesleukin PROLEUKIN 22 MILLION UNITS VL J0207 Amifostine, 500 MG Amifostine Crystalline ETHYOL 500 MG VIAL J9017 Arsenic Trioxide Inj, 1 MG Arsenic Trioxide TRISENOX 12 MG/6 ML VIAL J9025 Azacitidine Inj, 1 MG Azacitidine VIDAZA 100 MG VIAL J9030 Bcg Live Intravesical, 1 Mg BCG Live THERACYS 81 MG VIAL J9032 Belinostat Inj, 10 MG Belinostat BELEODAQ 500 MG VIAL J9036 Belrapzo Inj, 1 Mg Bendamustine Hcl BENDAMUSTINE 100 MG/4 ML VIAL J9033 Bendamustine Inj, 1 MG Bendamustine Hcl TREANDA 45 MG/0.5 ML VIAL J9034 Bendeka, 1 Mg Bendamustine Hcl BENDEKA 100 MG/4 ML VIAL J9035 Bevacizumab Inj, 10 MG Bevacizumab AVASTIN 400 MG/16 ML VIAL Bleomycin Sulfate Inj, 15 J9040 UNITS Bleomycin Sulfate BLEOMYCIN SULFATE 30U VIAL J9039 Blinatumomab Inj, 1 MCG Blinatumomab BLINCYTO 35MCG VIAL+STABILIZER J9041 Bortezomib Inj, 0.1 MG Bortezomib VELCADE 3.5 MG VIAL Brentuximab Vedotin Inj, 1 J9042 MG Brentuximab Vedotin ADCETRIS 50 MG VIAL J0594 Busulfan Inj, 1 MG Busulfan BUSULFEX 60 MG/10 ML VIAL J9043 Cabazitaxel Inj, 1 MG Cabazitaxel JEVTANA 60 MG/1.5 ML KIT Calaspargase Pegol-Mknl J9118 Inj, 10 Units Calaspargase Pegol-Mknl ASPARLAS 3,750 UNIT/5 ML VIAL J9045 Carboplatin Inj, 50 MG Carboplatin PARAPLATIN 600 MG/60 ML VIAL J9047 Carfilzomib Inj, 1 MG Carfilzomib KYPROLIS 60 MG VIAL J9050 Carmustine Inj, 100 MG Carmustine CARMUSTINE 100 MG VIAL J9055 Cetuximab Inj, 10 MG Cetuximab ERBITUX 200 MG/100 ML VIAL J9119 Chemotherapy Drug Cemiplimab-Rwlc LIBTAYO 350 MG/7 ML VIAL J9204 Chemotherapy Drug Mogamulizumab-Kpkc POTELIGEO 20 MG/5 ML VIAL J9060 Cisplatin Inj, 10 MG Cisplatin PLATINOL-AQ 1 MG/ML VIAL J9065 Cladribine Inj, 1 MG Cladribine LEUSTATIN 10 MG/10 ML VIAL J9027 Clofarabine Inj, 1 MG Clofarabine CLOLAR 20 MG/20 ML VIAL J9057 Copanlisib Inj, 1 Mg Copanlisib Di-Hcl ALIQOPA 60 MG VIAL J9100 Cytarabine Hcl Inj, 100 MG Cytarabine TARABINE PFS 20 MG/ML VIAL Cytarabine Liposome Inj, 10 J9098 MG Cytarabine Liposome/PF DEPOCYT 50 MG/5 ML VIAL J9130 Dacarbazine Inj, 100 MG Dacarbazine DTIC-DOME IV 200 MG VIAL J9120 Dactinomycin Inj, 0.5 MG Dactinomycin DACTINOMYCIN 0.5 MG VIAL Darbepoetin Alfa Non-Esrd, J0881 1 MCG Darbepoetin Alfa ARANESP 60 MCG/ML VIAL Daunorubicin Citrate Inj, 10 J9151 MG Daunorubicin Citrate Liposomal DAUNOXOME 50 MG (2 MG/ML) VIAL J9150 Daunorubicin Inj, 10 MG Daunorubicin Hcl DAUNORUBICIN 50 MG/10 ML VIAL Copyright © 2020 Oncology Analytics, Inc. All rights reserved. J0894 Decitabine Inj, 1 MG Decitabine DECITABINE 50 MG VIAL J9155 Degarelix Inj, 1 MG Degarelix Acetate FIRMAGON 80 MG VIAL Denileukin Diftitox Inj, 300 J9160 MCG Denileukin Diftitox ONTAK 150 MCG/ML VIAL J0897 Denosumab Inj, 1 MG Denosumab XGEVA 120 MG/1.7 ML VIAL J0897 Denosumab Inj, 1 MG Denosumab PROLIA Dexrazoxane Hcl Inj, 250 J1190 MG Dexrazoxane Hcl ZINECARD 500 MG VIAL J9171 Docetaxel Inj, 1 MG Docetaxel TAXOTERE 80 MG/4 ML VIAL Dolasetron Mesylate, 10 J1260 MG Dolasetron Mesylate ANZEMET 20 MG/ML VIAL J9000 Doxorubicin Hcl Inj, 10 MG Doxorubicin Hcl RUBEX 50 MG VIAL DOXORUBICIN LIPOSOME Q2050 Doxorubicin Inj, 10 MG Doxorubicin Hcl Pegylated Liposomal 50MG/25ML J9173 Durvalumab Inj, 10 Mg Durvalumab IMFINZI 500 MG/10 ML VIAL J9178 Epirubicin Hcl Inj, 2 MG Epirubicin Hcl EPIRUBICIN HCL 50 MG VIAL Epoetin Alfa Non-Esrd, J0885 1000 UNITS Epoetin Alfa PROCRIT 40,000 UNITS/ML VIAL Eribulin Mesylate Inj, 0.1 J9179 MG Eribulin Mesylate HALAVEN 1 MG/2 ML VIAL J9019 Erwinaze Inj, 1000 IU Asparaginase (Erwinia Chrysanthemi) ERWINAZE 10,000 UNITS VIAL J9181 Etoposide Inj, 10 MG Etoposide VEPESID 20 MG/ML VIAL J9181 Etoposide Inj, 10 MG Etoposide Phosphate ETOPOPHOS 100 MG VIAL J1442 Filgrastim G-Csf Inj, 1 MCG Filgrastim NEUPOGEN 480 MCG/1.6 ML VIAL Immune Globulin,Gamma J1572 Flebogamma Inj, 500 MG (Igg)/Sorbitol/Iga 0 To 50 Mcg/Ml FLEBOGAMMA DIF 5% VIAL J9200 Floxuridine Inj, 500 MG Floxuridine FUDR 500 MG VIAL Fludarabine Phosphate Inj, J9185 50 MG Fludarabine Phosphate FLUDARABINE 50 MG/2 ML VIAL J9190 Fluorouracil Inj, 500 MG Fluorouracil FLUOROURACIL 500 MG/10 ML VIAL J1453 Fosaprepitant Inj, 1 MG Fosaprepitant Dimeglumine EMEND 150 MG VIAL Q5108 Fulphila Inj, 0.5 MG Pegfilgrastim-Jmdb FULPHILA 6 MG/0.6 ML SYRINGE J9395 Fulvestrant Inj, 25 MG Fulvestrant FULVESTRANT 250 MG/5 ML SYRNG J1460 Gamma Globulin Inj, 1 CC Immune Globulin,Gamma(Igg) IMMUNE SERUM GLOBULIN VIAL J1460 Gamma Globulin Inj, 1 CC Immune Globulin,Gamma(Igg)/Glycine GAMASTAN VIAL Immune Gammagard Liquid Inj, 500 Globulin,Gamm(Igg)/Glycine/Iga Greater J1569 MG Than 50 Mcg/Ml GAMMAGARD LIQUID 10% VIAL Immune Globulin,Gamm(Igg)/Sorbitol/Glycin/Iga J1557 Gammaplex Inj, 500 MG 0 To 50 Mcg/Ml GAMMAPLEX 5 GRAM/100 ML VIAL Immune Globulin,Gamma J1557 Gammaplex Inj, 500 MG (Igg)/Glycine/Iga 0 To 50 Mcg/Ml GAMMAPLEX 5 GRAM/50 ML VIAL Copyright © 2020 Oncology Analytics, Inc. All rights reserved. Immune Gamunex-C/Gammaked, Globulin,Gamm(Igg)/Glycine/Iga Greater J1561 500 MG Than 50 Mcg/Ml GAMUNEX 10% VIAL Gamunex-C/Gammaked, J1561 500 MG Immune Globulin,Gamma Caprylate (Igg) GAMMAKED Immune Gamunex-C/Gammaked, Globulin,Gamma(Igg)/Glycine/Iga J1561 500 MG Average 46 Mcg/Ml GAMUNEX-C 5 GRAM/50 ML VIAL Gemcitabine Hcl Inj, 200 J9201 MG Gemcitabine Hcl GEMZAR 200 MG VIAL Gemcitabine Hcl Inj, 200 Gemcitabine Hcl In 0.9 % Sodium J9201 MG Chloride INFUGEM 2,200 MG/220 ML BAG Gemtuzumab Ozogamicin, J9203 0.1 Mg Gemtuzumab Ozogamicin MYLOTARG 4.5 MG VIAL Goserelin Acetate Implant, J9202 3.6 MG Goserelin Acetate ZOLADEX 3.6 MG IMPLANT SYRN Granisetron Hcl Inj, 100 J1626 MCG Granisetron Hcl KYTRIL 4 MG/4 ML VIAL Herceptin Hylecta Inj, 10 J9356 Mg Trastuzumab-Hyaluronidase-Oysk HERCEPTIN HYLECTA 600MG-10,000 Immune Globulin,Gamma J1559 Hizentra Inj, 100 MG (Igg)/Proline/Iga 0 To 50 Mcg/Ml HIZENTRA 4 GRAM/20 ML VIAL Hyqvia Immuneglobulin, Immune Globulin,Gamma(Igg) J1575 100 MG Human/Hyaluronidase, Human Recomb HYQVIA 5 GM-400 UNIT PACK J9211 Idarubicin Hcl Inj, 5 MG Idarubicin Hcl IDARUBICIN PFS 5 MG/5 ML VIAL J9208 Ifosfamide Inj, 1 GM Ifosfamide IFOSFAMIDE 3 GM/60 ML VIAL Immune Imm Glob Bivigam Inj, 500 Globulin,Gamm(Igg)/Glycine/Iga Greater J1556 MG Than 50 Mcg/Ml BIVIGAM LIQUID 10% VIAL Immune Immune Globulin Powder, Globulin,Gamm(Igg)/Glycine/Glucose/Iga J1566 500 MG 0 To 50 Mcg/Ml GAMMAGARD S-D 5 GM VL W/SET Immune Immune Globulin Powder, Globulin,Gamm(Igg)/Sucrose/Iga Greater J1566 500 MG Than 50 Mcg/Ml CARIMUNE NF 6 GM VIAL Imported Lipodox Inj, 10 Q2049 MG Doxorubicin Hcl Pegylated Liposomal LIPODOX 50 2 MG/ML VIAL J0185 Inj Aprepitant, 1 Mg Aprepitant CINVANTI 130 MG/18 ML VIAL J9022 Inj Atezolizumab, 10 Mg Atezolizumab TECENTRIQ 840 MG/14 ML VIAL J9044 Inj Bortezomib Nos, 0.1 Mg Bortezomib BORTEZOMIB 3.5 MG VIAL Immune Globulin,Gamm(Igg)/Glycine/Iga Greater J1555 Inj Cuvitru, 100 Mg Than 50 Mcg/Ml CUVITRU 8 GRAM/ 40 ML VIAL J9145 Inj Daratumumab, 10 Mg Daratumumab DARZALEX 400 MG/20 ML VIAL Inj Daunorubicin J9153 Cytarabine, 1-2.27 Mg Daunorubicin/Cytarabine Liposomal VYXEOS 44 MG-100 MG VIAL Copyright © 2020 Oncology Analytics, Inc. All rights reserved. J9176 Inj Elotuzumab, 1 Mg Elotuzumab EMPLICITI 400 MG VIAL Inj Fosnetupitant Fosnetupitant Chloride Hcl/Palonosetron J1454 Palonoset, 0.25 MG Hcl AKYNZEO 235-0.25 MG VIAL J1627 Inj Granisetronxr, 0.1 Mg Granisetron SUSTOL 10 MG/0.4 ML SYRINGE Inj Moxetumomab J9313 Pasudotox-Tdfk, 0.01 Mg Moxetumomab Pasudotox-Tdfk LUMOXITI 1 MG VIAL J9285 Inj Olaratumab, 10 Mg Olaratumab LARTRUVO 500 MG/50 ML VIAL Inj Retacrit Non-Esrd Use, Q5106 1000 Units Epoetin Alfa-Epbx RETACRIT 40,000 UNIT/ML VIAL Inj Rituximab Rituximab/Hyaluronidase, Human J9311 Hyaluronidase, 10 Mg Recombinant RITUXAN HYCELA 1,600 MG-26,800 Inj Talimogene Laherparepvec, 1000000 J9325 PFU Talimogene Laherparepvec IMLYGIC 100 MILLION PFU/ML VL Q5117 Inj., Kanjinti, 10 Mg Trastuzumab-Anns KANJINTI 420 MG VIAL Q5118 Inj., Zirabev, 10 Mg Bevacizumab-Bvzr ZIRABEV J9023 Injection Avelumab, 10 Mg Avelumab BAVENCIO 200 MG/10 ML VIAL Injection Levoleucovorin, 1 J0642 Mg Levoleucovorin KHAPZORY 300 MG VIAL Injection Trabectedin, 0.1 J9352 Mg Trabectedin YONDELIS 1 MG VIAL Injection, Gamma Globulin, J1560 Intramuscular, Over 10 Cc Gamma Globulin > 10 Cc Inj GamaSTAN S/D Injection, Immune Globulin, Intravenous, Non- Lyophilized (E.G., Liquid), Not Otherwise Specified, J1599 500 Mg Immune Globulin ASCENIV Injection, Immune Globulin, Intravenous, Non- Lyophilized (E.G., Liquid), Not Otherwise Specified, Immune Globulin,Gamma(Igg)-Ifas J1599 500 Mg Human/Glycine PANZYGA 10% (5 G/50 ML) VIAL Injection, Rituximab-Abbs, Q5115 10 Mg Rituximab-Abbs TRUXIMA Injection, Trastuzumab- Dkst, Biosimilar, (Ogivri), 10 Q5114 Mg Trastuzumab-Dkst OGIVRI Injection, Trastuzumab- Dttb, Biosimilar Q5112 (Ontruzant), 10 Mg Trastuzumab-Dttb ONTRUZANT Injection, Trastuzumab- Q5113 Pkrb, 10 Mg Trastuzumab-Pkrb HERZUMA Injection, Trastuzumab- Qyyp, Biosimilar, Q5116 (Trazimera), 10 Mg Trastuzumab-Qyyp TRAZIMERA Copyright © 2020 Oncology Analytics, Inc. All rights reserved. Inotuzumab Ozogam Inj, J9229 0.1 Mg Inotuzumab Ozogamicin BESPONSA 0.9 MG VIAL Iodine I-131 Iobenguane A9699 Tx,1 Millicurie Iobenguane Iodine 131 AZEDRA THERAPEUTIC VIAL J9228 Ipilimumab Inj, 1 MG Ipilimumab YERVOY 50 MG/10 ML VIAL J9206 Irinotecan Inj, 20 MG Irinotecan Hcl IRINOTECAN HCL 500 MG/25 ML VL Irinotecan
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