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Home , Dinutuximab, Polatuzumab vedotin

Banner Health Network Medical Oncology Code List

Description Alt Descriptions HCPCS Codes Drug Class

5-Fluorouracil 5FU, Adrucil J9190 Primary Ado- Emtansine Kadcyla J9354 Primary Aldesleukin Proleukin, Interleukin-2 J9015 Primary Aprepitant Cinvanti J0185 Supportive - Antiemetic Arsenic Trioxide Trisenox J9017 Primary Asparaginase Erwinaze J9019 Primary Tecentriq J9022 Primary Avelumab Bavencio J9023 Primary Azacitidine Vidaza J9025 Primary BCG TheraCys, Tice J9030 Primary Belinostat Beleodaq J9032 Primary Treanda J9033 Primary Bendamustine HCL Belrapzo J9036 Primary Bendamustine HCL Bendeka J9034 Primary Avastin J9035 Primary Bevacizumab-awwb (not currently available on the Mvasi Q5107 Primary market) Bevacizumab-bvzr Zirabev Q5118 Primary Bleomycin Blenoxane J9040 Primary Blincyto J9039 Primary Bortezomib (not otherwise Bortezomib J9044 Primary specified) Bortezomib Velcade J9041 Primary Adcetris J9042 Primary Cabazitaxel Jevtana J9043 Primary Calaspargase pegol-mknl Asparlas J9118 Primary

V1.2019 Effective: 7/1/2019 Description Alt Descriptions HCPCS Codes Drug Class

Carboplatin Paraplatin J9045 Primary Carfilzomib Kyprolis J9047 Primary Carmustine BiCNU, BCNU J9050 Primary Cemiplimab-rwlc Libtayo J9119 Primary Erbitux J9055 Primary Cisplatin Platinol J9060 Primary Cladribine Leustatin J9065 Primary Clofarabine Clolar J9027 Primary Copanlisib Aliqopa J9057 Primary Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Primary Cytarabine Ara-C J9100 Primary Cytarabine-Liposome DepoCyt J9098 Primary Dacarbazine DTIC-Dome J9130 Primary Dactinomycin Cosmegen, Actinomycin J9120 Primary Darzalex J9145 Primary Darbepoetin alfa Aranesp J0881 Supportive Daunorubicin Cerubidine J9150 Primary Decitabine Dacogen J0894 Primary Degarelix Firmagon J9155 Primary Denosumab Xgeva, Prolia J0897 Supportive Unituxin C9399 Primary Dinutuximab Unituxin J9999 Primary Docetaxel Taxotere J9171 Primary Doxorubicin HCL Adriamycin J9000 Primary

Doxil, Doxorubicin HCL (Liposomal) Doxorubicin HCL (liposomal) Q2050 Primary not otherwise specified

Durvalumab Imfinzi J9173 Primary Empliciti J9176 Primary Epirubicin Ellence J9178 Primary Epoetin alfa Epogen, Procrit J0885 Supportive Epoetin alfa-epbx Retacrit Q5106 Supportive Eribulin mesylate Halaven J9179 Primary

V1.2019 Effective: 7/1/2019 Description Alt Descriptions HCPCS Codes Drug Class

Etoposide - inj Toposar, VePesid, Etopophos J9181 Primary Filgrastim Neupogen J1442 Supportive Filgrastim-aafi Nivestym Q5110 Supportive Filgrastim-sndz Zarxio Q5101 Supportive Floxuridine FUDR J9200 Primary Fludarabine Phosphate Fludara, Oforta J9185 Primary Fosaprepitant Emend J1453 Supportive - Antiemetic Fosnetupitant/Palonosetron Akynzeo J1454 Supportive - Antiemetic Fulvestrant Faslodex J9395 Primary Gemcitabine Gemzar J9201 Primary Gemcitabine HCL Infugem C9399 Primary Gemcitabine HCL Infugem J9999 Primary Mylotarg J9203 Primary Goserelin acetate implant Zoladex J9202 Primary Granisetron Sustol J1627 Supportive - Antiemetic Histrelin Implant Vantas J9225 Primary Idarubicin HCL - inj Idamycin J9211 Primary Ifosfamide Ifex, Mitoxana J9208 Primary Besponsa J9229 Primary Interferon, alfa-2b, recombinant Intron A J9214 Primary Interferon, gamma-1b Actimmune J9216 Primary Ipilumumab Yervoy J9228 Primary Irinotecan Camptosar J9206 Primary Irinotecan Liposome Onivyde J9205 Primary Ixabepilone Ixempra J9207 Primary Lanreotide Somatuline Depot J1930 Primary Leucovorin - inj Leucovorin J0640 Primary Eligard, Lupron Depot, Lupron, Leuprolide Acetate (J1950: 3.75mg) J1950 Primary Leuprolide Acetate Eligard, Lupron Depot, Lupron, Leuprolide Acetate (J9217: 7.5mg) J9217 Primary Leuprolide Acetate Eligard, Lupron Depot, Lupron, Leuprolide Acetate (J9218: 1mg) J9218 Primary Leuprolide Acetate

V1.2019 Effective: 7/1/2019 Description Alt Descriptions HCPCS Codes Drug Class

Levoleucovorin Fusilev J0641 Primary Levoleucovorin Khapzory J0642 Primary Liposome-encapsulated combination of Vyxeos J9153 Primary Daunorubicin and Cytarabine Mechlorethamine HCL Mustragen J9230 Primary Melphalan HCL - inj Alkeran J9245 Primary Mesna Mesnex J9209 Supportive Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Primary Methotrexate Sodium (J9260: 50mg) Folex, Methotrexate J9260 Primary Mitomycin Mutamycin J9280 Primary Mitoxantrone HCL Novantrone J9293 Primary Mogamulizumab-kpkc Poteligeo J9204 Primary -tdfk Lumoxiti J9313 Primary Portrazza J9295 Primary Nelarabine Arranon J9261 Primary Opdivo J9299 Primary Gazyva J9301 Primary Octreotide depot Sandostatin J2353 Primary Octreotide non-depot Sandostatin J2354 Primary Arzerra J9302 Primary Lartruvo J9285 Primary Omacetaxine Synribo J9262 Primary Oxaliplatin Eloxatin J9263 Primary Paclitaxel Nov-Onxol, Taxol J9267 Primary Paclitaxel (albumin-bound) Abraxane J9264 Primary Palonosetron Aloxi J2469 Supportive - Antiemetic Pamidronate Disodium Aredia J2430 Supportive Vectibix J9303 Primary Pegaspargase Oncaspar J9266 Primary Pegfilgrastim Neulasta J2505 Supportive Pegfilgrastim-cbqv Udenyca Q5111 Supportive Pegfilgrastim-jmdb Fulphila Q5108 Supportive

V1.2019 Effective: 7/1/2019 Description Alt Descriptions HCPCS Codes Drug Class

Peginterferon, alfa-2a Pegasys J3590 Primary Peginterferon, alfa-2a Pegasys S0145 Primary Peginterferon, alfa-2b PegIntron S0148 Primary Peginterferon, alfa-2b PegIntron J3590 Primary Peginterferon, alfa-2b Sylatron C9399 Primary Peginterferon, alfa-2b Sylatron J9999 Primary Keytruda J9271 Primary Pemetrexed Alimta J9305 Primary Pentostatin Nipent J9268 Primary Perjeta J9306 Primary -piiq Polivy C9399 Primary Polatuzumab vedotin-piiq Polivy J9999 Primary Porfimer Sodium Photofrin J9600 Primary Pralatrexate Folotyn J9307 Primary Cyramza J9308 Primary Rituxan J9312 Primary Rituximab and Hyaluronidase Human Rituxan Hycela J9311 Primary Rituximab-abbs Truxima Q5115 Primary Rituximab-pvvr Ruxience C9399 Primary Rituximab-pvvr Ruxience J3490 Primary Rituximab-pvvr Ruxience J3590 Primary Rituximab-pvvr Ruxience J9999 Primary Romidepsin Istodax J9315 Primary Sargramostim Leukine J2820 Supportive Sylvant J2860 Primary Sipuleucel-T Provenge Q2043 Primary Streptozocin Zanosar J9320 Primary Tagraxofusp-erzs Elzonris J9269 Primary Talimogene Laherparepvec Imlygic J9325 Primary Tbo-filgrastim Granix J1447 Supportive Temozolomide - inj Temodar J9328 Primary Torisel J9330 Primary

V1.2019 Effective: 7/1/2019 Description Alt Descriptions HCPCS Codes Drug Class

Teniposide Vumon Q2017 Primary Thiotepa Thioplex J9340 Primary Tocilizumab Actemra J3262 Primary Topotecan - inj Hycamtin J9351 Primary Trabectedin Yondelis J9352 Primary Trastuzumab Herceptin J9355 Primary Trastuzumab and hyaluronidase-oysk Herceptin Hylecta J9356 Primary Trastuzumab-anns effective 10/1/19 Kanjinti Q5117 Primary Trastuzumab-dkst Ogivri Q5114 Primary Trastuzumab-dttb Ontruzant Q5112 Primary Trastuzumab-pkrb Herzuma Q5113 Primary Trastuzumab-qyyp Trazimera Q5116 Primary Triptorelin Pamoate Trelstar J3315 Primary Valrubicin Valstar J9357 Primary Vinblastine Sulfate Velban J9360 Primary Vincristine Sulfate Oncovin, Vincasar PFS J9370 Primary Vincristine Sulfate Liposome Marqibo J9371 Primary Vinorelbine Tartrate Navelbine J9390 Primary Zivafibercept Zaltrap J9400 Primary Zoledronic Acid Zometa J3489 Supportive CPT® copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

V1.2019 Effective: 7/1/2019