Health Partners Plans (HPP) – Medical Oncology Code List This list is constantly evolving as new drugs come to market and are approved by the FDA, as well as any HPCP code changes issued by CMS. If the drug you are searching for does not appear on this list, please access the Evicore – HPP provider resource site: www.evicore.com/resources/healthplan/health-partners-plans For Medicaid only: Drugs on this list may be non-preferred agents or require clinical Prior Authorization according to the Pennsylvania statewide Preferred Drug List (PDL). The current list of Non-preferred agents and Prior Authorization requirements, as well as applicable criteria, can be found in the link below. Pennsylvania PDL list: https://papdl.com/sites/default/files/ghs-files/Penn%20Statewide%20PDL%2001.05.21.pdf

Description HCPCs Alt Drug Administration HPP Drug Reviewer code Descriptions2 Class Technique (Health Comments Partners Plan) Romidepsin (non- C9065 Romidepsin, Primary INJECTABLE Y Code deleted eviCore lypohilized) non- 6/30/21 lypohilized C9078 Cosela Supportive INJECTABLE Y C9078 - new eviCore code effective 7/1/21 Melphalan Flufenamide C9080 Pepaxto Primary INJECTABLE Y C9080 - new eviCore code effective 7/1/21 -vmjw C9399 Rybrevant Primary INJECTABLE Y New Drug eviCore 5/28/21 Dinutuximab C9399 Unituxin Primary INJECTABLE Y eviCore -gxly C9399 Jemperli Primary INJECTABLE Y New Drug eviCore 4/30/21 Loncastuximab tesirine-lpyl C9399 Zynlonta Primary INJECTABLE Y New Drug eviCore 4/30/21 Aprepitant J0185 Cinvanti Supportive INJECTABLE Y - except - for Antiemetic Medicaid (This is a eviCore preferred drug for Medicaid and does not require Prior Auth) Burosumab J0584 Crysvita Supportive INJECTABLE Y eviCore

Leucovorin - inj J0640 Leucovorin Primary INJECTABLE Y eviCore Levoleucovorin J0641 Fusilev Primary INJECTABLE Y eviCore

Levoleucovorin J0642 Khapzory Primary INJECTABLE Y eviCore

Darbepoetin alfa J0881 Aranesp Supportive INJECTABLE Y eviCore Epoetin alfa J0885 Epogen, Supportive INJECTABLE Y eviCore Procrit Decitabine J0894 Dacogen Primary INJECTABLE Y eviCore

Luspatercept-aamt J0896 Reblozyl Supportive INJECTABLE Y eviCore

Denosumab J0897 Xgeva, Prolia Supportive INJECTABLE Y eviCore Filgrastim J1442 Neupogen Supportive INJECTABLE Y eviCore

Tbo-filgrastim J1447 Granix Supportive INJECTABLE Y eviCore Fosaprepitant J1453 Emend Supportive INJECTABLE Y eviCore - Antiemetic Fosnetupitant/Palonosetron J1454 Akynzeo Supportive INJECTABLE Y eviCore - Antiemetic Granisetron J1627 Sustol Supportive INJECTABLE Y eviCore - Antiemetic Lanreotide J1930 Somatuline Primary INJECTABLE Y eviCore Depot Lanreotide J1930 Somatuline Supportive INJECTABLE Y eviCore Depot Leuprolide Acetate (J1950: J1950 Eligard, Primary INJECTABLE Y eviCore 3.75mg) Lupron Depot, Lupron, Leuprolide Acetate Octreotide depot J2353 Sandostatin Primary INJECTABLE Y eviCore

Octreotide depot J2353 Sandostatin Supportive INJECTABLE Y eviCore Octreotide non-depot J2354 Sandostatin Primary INJECTABLE Y eviCore

Octreotide non-depot J2354 Sandostatin Supportive INJECTABLE Y eviCore

Pamidronate Disodium J2430 Aredia Supportive INJECTABLE Y - except eviCore for Medicaid (This is a preferred drug for Medicaid and does not require Prior Auth) Palonosetron J2469 Aloxi Supportive INJECTABLE Y - except eviCore - for Antiemetic Medicaid (This is a preferred drug for Medicaid and does not require Prior Auth) Pegfilgrastim J2505 Neulasta Supportive INJECTABLE Y eviCore

Sargramostim J2820 Leukine Supportive INJECTABLE Y eviCore Siltuximab J2860 Sylvant Primary INJECTABLE Y eviCore

Tocilizumab J3262 Actemra Primary INJECTABLE Y eviCore

Triptorelin Pamoate J3315 Trelstar Primary INJECTABLE Y eviCore Zoledronic Acid J3489 Zoledronic Supportive INJECTABLE Y - except eviCore Acid for Medicaid (This is a preferred drug for Medicaid and does not require Prior Auth) Peginterferon, alfa-2a J3590 Pegasys Primary INJECTABLE Y eviCore

Peginterferon, alfa-2b J3590 PegIntron Primary INJECTABLE Y eviCore

Doxorubicin HCL J9000 Adriamycin Primary INJECTABLE Y eviCore Aldesleukin J9015 Proleukin, Primary INJECTABLE Y eviCore Interleukin-2 Arsenic Trioxide J9017 Trisenox Primary INJECTABLE Y eviCore Asparaginase J9019 Erwinaze Primary INJECTABLE Y eviCore

Atezolizumab J9022 Tecentriq Primary INJECTABLE Y eviCore

Avelumab J9023 Bavencio Primary INJECTABLE Y eviCore Azacitidine J9025 Vidaza Primary INJECTABLE Y eviCore

Clofarabine J9027 Clolar Primary INJECTABLE Y eviCore BCG J9030 TheraCys, Primary INJECTABLE Y eviCore Tice Belinostat J9032 Beleodaq Primary INJECTABLE Y eviCore

Bendamustine hcl J9033 Treanda Primary INJECTABLE Y eviCore

Bendamustine HCL J9034 Bendeka Primary INJECTABLE Y eviCore J9035 Avastin Primary INJECTABLE Y eviCore

Bendamustine HCL J9036 Belrapzo Primary INJECTABLE Y eviCore

Belantamab Mafodotin-blmf J9037 Blenrep Primary INJECTABLE Y eviCore

Blinatumomab J9039 Blincyto Primary INJECTABLE Y eviCore

Bleomycin J9040 Blenoxane Primary INJECTABLE Y eviCore Bortezomib J9041 Velcade Primary INJECTABLE Y eviCore

Brentuximab Vedotin J9042 Adcetris Primary INJECTABLE Y eviCore

Cabazitaxel J9043 Jevtana Primary INJECTABLE Y eviCore Bortezomib J9044 Bortezomib Primary INJECTABLE Y eviCore (not otherwise specified) Carboplatin J9045 Paraplatin Primary INJECTABLE Y eviCore Carfilzomib J9047 Kyprolis Primary INJECTABLE Y eviCore

Carmustine J9050 BiCNU, BCNU Primary INJECTABLE Y eviCore

Cetuximab J9055 Erbitux Primary INJECTABLE Y eviCore Copanlisib J9057 Aliqopa Primary INJECTABLE Y eviCore

Cisplatin J9060 Platinol Primary INJECTABLE Y eviCore Cladribine J9065 Leustatin Primary INJECTABLE Y eviCore

Cyclophosphamide - inj J9070 Cytoxan, Primary INJECTABLE Y eviCore Endoxan-Asta Cytarabine-Liposome J9098 DepoCyt Primary INJECTABLE Y eviCore Cytarabine J9100 Ara-C Primary INJECTABLE Y eviCore

Calaspargase pegol-mknl J9118 Asparlas Primary INJECTABLE Y eviCore

Cemiplimab-rwlc J9119 Libtayo Primary INJECTABLE Y eviCore Dactinomycin J9120 Cosmegen, Primary INJECTABLE Y eviCore Actinomycin Dacarbazine J9130 DTIC-Dome Primary INJECTABLE Y eviCore

Daratumumab and J9144 Darzalex Primary INJECTABLE Y eviCore hyaluronidase-fihj Faspro

Daratumumab J9145 Darzalex Primary INJECTABLE Y eviCore Daunorubicin J9150 Cerubidine Primary INJECTABLE Y eviCore

Liposome-encapsulated J9153 Vyxeos Primary INJECTABLE Y eviCore combination of Daunorubicin and Cytarabine

Degarelix J9155 Firmagon Primary INJECTABLE Y eviCore

Docetaxel J9171 Taxotere Primary INJECTABLE Y eviCore

Durvalumab J9173 Imfinzi Primary INJECTABLE Y eviCore Elotuzumab J9176 Empliciti Primary INJECTABLE Y eviCore

Enfortumb vedotin-ejfv J9177 Padcev Primary INJECTABLE Y eviCore Epirubicin J9178 Ellence Primary INJECTABLE Y eviCore

Eribulin mesylate J9179 Halaven Primary INJECTABLE Y eviCore

Etoposide - inj J9181 Toposar, Primary INJECTABLE Y eviCore VePesid, Etopophos Fludarabine Phosphate J9185 Fludara, Primary INJECTABLE Y eviCore Oforta 5-Fluorouracil- Injection J9190 5FU, Adrucil Primary INJECTABLE Y eviCore

Gemcitabine HCL in NaCL J9198 Infugem Primary INJECTABLE Y eviCore

Floxuridine J9200 FUDR Primary INJECTABLE Y eviCore

Gemcitabine J9201 Gemzar Primary INJECTABLE Y eviCore Goserelin acetate implant J9202 Zoladex Primary INJECTABLE Y eviCore

Gemtuzumab Ozogamicin J9203 Mylotarg Primary INJECTABLE Y eviCore

Mogamulizumab-kpkc J9204 Poteligeo Primary INJECTABLE Y eviCore

Irinotecan Liposome J9205 Onivyde Primary INJECTABLE Y eviCore

Irinotecan J9206 Camptosar Primary INJECTABLE Y eviCore Ixabepilone J9207 Ixempra Primary INJECTABLE Y eviCore

Ifosfamide J9208 Ifex, Mitoxana Primary INJECTABLE Y eviCore Idarubicin HCL - inj J9211 Idamycin Primary INJECTABLE Y eviCore

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

Leuprolide Acetate (J9217: J9217 Eligard, Primary INJECTABLE Y eviCore 7.5mg) Lupron Depot, Lupron, Leuprolide Acetate Leuprolide Acetate (J9218: J9218 Eligard, Primary INJECTABLE Y eviCore 1mg) Lupron Depot, Lupron, Leuprolide Acetate Lurbinectedin J9223 Zepzelca Primary INJECTABLE Y eviCore

Histrelin Implant J9225 Vantas Primary INJECTABLE Y eviCore Isatuximab-irfc J9227 Sarclisa Primary INJECTABLE Y eviCore Ipilumumab J9228 Yervoy Primary INJECTABLE Y eviCore

Inotuzumab Ozogamicin J9229 Besponsa Primary INJECTABLE Y eviCore Mechlorethamine HCL J9230 Mustragen Primary INJECTABLE Y eviCore

Melphalan HCL - NOS inj J9245 Alkeran Primary INJECTABLE Y eviCore

Melphalan HCL - inj J9246 Evomela Primary INJECTABLE Y eviCore Methotrexate Sodium J9250 Folex, Primary INJECTABLE Y eviCore (J9250: 5mg) Methotrexate

Methotrexate Sodium J9260 Folex, Primary INJECTABLE Y eviCore (J9260: 50mg) Methotrexate

Nelarabine J9261 Arranon Primary INJECTABLE Y eviCore

Omacetaxine J9262 Synribo Primary INJECTABLE Y eviCore

Oxaliplatin J9263 Eloxatin Primary INJECTABLE Y eviCore Paclitaxel (albumin-bound) J9264 Abraxane Primary INJECTABLE Y eviCore

Pegaspargase J9266 Oncaspar Primary INJECTABLE Y eviCore

Paclitaxel J9267 Nov-Onxol, Primary INJECTABLE Y eviCore Taxol Pentostatin J9268 Nipent Primary INJECTABLE Y eviCore Tagraxofusp-erzs J9269 Elzonris Primary INJECTABLE Y eviCore

Pembrolizumab J9271 Keytruda Primary INJECTABLE Y eviCore Mitomycin J9280 Mutamycin Primary INJECTABLE Y eviCore Mitomycin J9281 Jelmyto Primary PYELOCALYCEAL Y Medicare Part B eviCore

Mitoxantrone HCL J9293 Novantrone Primary INJECTABLE Y eviCore Necitumumab J9295 Portrazza Primary INJECTABLE Y eviCore

Nivolumab J9299 Opdivo Primary INJECTABLE Y eviCore

Obinutuzumab J9301 Gazyva Primary INJECTABLE Y eviCore J9302 Arzerra Primary INJECTABLE Y eviCore

Panitumumab J9303 Vectibix Primary INJECTABLE Y eviCore Pemetrexed J9304 Pemfexy Primary INJECTABLE Y eviCore

Pemetrexed J9305 Alimta Primary INJECTABLE Y eviCore

Pertuzumab J9306 Perjeta Primary INJECTABLE Y eviCore Pralatrexate J9307 Folotyn Primary INJECTABLE Y eviCore

Ramucirumab J9308 Cyramza Primary INJECTABLE Y eviCore

Polatuzumab vedotin-piiq J9309 Polivy Primary INJECTABLE Y eviCore

Rituximab and J9311 Rituxan Primary INJECTABLE Y eviCore Hyaluronidase Human Hycela

Rituximab J9312 Rituxan Primary INJECTABLE Y eviCore Moxetumomab pasudotox- J9313 Lumoxiti Primary INJECTABLE Y eviCore tdfk

Romidepsin (lypohilized) J9315 Istodax Primary INJECTABLE Y eviCore Pertuzumab / / J9316 Phesgo Primary INJECTABLE Y eviCore hyaluronidase-zzxf

Sacituzumab govitecan-hziy J9317 Trodelvy Primary INJECTABLE Y eviCore

Streptozocin J9320 Zanosar Primary INJECTABLE Y eviCore

Talimogene Laherparepvec J9325 Imlygic Primary INJECTABLE Y eviCore

Temozolomide - inj J9328 Temodar Primary INJECTABLE Y eviCore J9330 Torisel Primary INJECTABLE Y eviCore

Thiotepa J9340 Thioplex Primary INJECTABLE Y eviCore Naxitamab-gqgk J9348 Danyelza Primary INJECTABLE Y J9348 - new eviCore code effective 7/1/21 Tafasitamab-cxix J9349 Monjuvi Primary INJECTABLE Y eviCore

Topotecan - inj J9351 Hycamtin Primary INJECTABLE Y eviCore Trabectedin J9352 Yondelis Primary INJECTABLE Y eviCore

Margetuximab-cmkb J9353 Margenza Primary INJECTABLE Y J9353 - new eviCore code effective 7/1/21 Ado-Trastuzumab J9354 Kadcyla Primary INJECTABLE Y eviCore Emtansine

Trastuzumab J9355 Herceptin Primary INJECTABLE Y eviCore Trastuzumab and J9356 Herceptin Primary INJECTABLE Y eviCore hyaluronidase-oysk Hylecta

Valrubicin J9357 Valstar Primary INJECTABLE Y eviCore Fam-trastuzumab J9358 Enhertu Primary INJECTABLE Y eviCore deruxtecan-nxki

Vinblastine Sulfate J9360 Velban Primary INJECTABLE Y eviCore

Vincristine Sulfate J9370 Oncovin, Primary INJECTABLE Y eviCore Vincasar PFS Vincristine Sulfate J9371 Marqibo Primary INJECTABLE Y eviCore Liposome Vinorelbine Tartrate J9390 Navelbine Primary INJECTABLE Y eviCore Fulvestrant J9395 Faslodex Primary INJECTABLE Y eviCore

Zivafibercept J9400 Zaltrap Primary INJECTABLE Y eviCore

Porfimer Sodium J9600 Photofrin Primary INJECTABLE Y eviCore Melphalan Flufenamide J9999 Pepaxto Primary INJECTABLE Y eviCore

Trilaciclib J9999 Cosela Supportive INJECTABLE Y eviCore

Amivantamab-vmjw J9999 Rybrevant Primary INJECTABLE Y New Drug eviCore 5/28/21 Dinutuximab J9999 Unituxin Primary INJECTABLE Y eviCore Dostarlimab-gxly J9999 Jemperli Primary INJECTABLE Y New Drug eviCore 4/30/21 Loncastuximab tesirine-lpyl J9999 Zynlonta Primary INJECTABLE Y New Drug eviCore 4/30/21 Teniposide Q2017 Vumon Primary INJECTABLE Y eviCore

Sipuleucel-T Q2043 Provenge Primary INJECTABLE Y eviCore Doxorubicin HCL Q2050 Doxil, Primary INJECTABLE Y eviCore (liposomal) Doxorubicin HCL (Liposomal) not otherwise specified Epoetin alfa-epbx Q5106 Retacrit Supportive INJECTABLE Y eviCore

Bevacizumab-awwb Q5107 Mvasi Primary - INJECTABLE Y eviCore Biosimilar Pegfilgrastim-jmdb Q5108 Fulphila Supportive INJECTABLE Y eviCore Filgrastim-aafi Q5110 Nivestym Supportive INJECTABLE Y eviCore

Pegfilgrastim-cbqv Q5111 Udenyca Supportive INJECTABLE Y eviCore Trastuzumab-dttb Q5112 Ontruzant Primary - INJECTABLE Y eviCore Biosimilar Trastuzumab-pkrb Q5113 Herzuma Primary - INJECTABLE Y eviCore Biosimilar Trastuzumab-dkst Q5114 Ogivri Primary - INJECTABLE Y eviCore Biosimilar Rituximab-abbs Q5115 Truxima Primary - INJECTABLE Y eviCore Biosimilar Trastuzumab-qyyp Q5116 Trazimera Primary - INJECTABLE Y eviCore Biosimilar Trastuzumab-anns Q5117 Kanjinti Primary - INJECTABLE Y eviCore Biosimilar Bevacizumab-bvzr Q5118 Zirabev Primary - INJECTABLE Y eviCore Biosimilar Rituximab-pvvr Q5119 Ruxience Primary - INJECTABLE Y eviCore Biosimilar Pegfilgrastim-bmez Q5120 Ziextenzo Supportive INJECTABLE Y eviCore

Pegfilgrastim-apgf Q5122 Nyvepria Supportive INJECTABLE Y eviCore Rituximab-arrx Q5123 Riabni Primary INJECTABLE Y Q5123 - new eviCore code effective 7/1/21