Health Partners Plan - Medical Oncology List Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique 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 Tecentriq J9022 Y INJECTABLE Primary Avelumab Bavencio J9023 Y INJECTABLE Primary Azacitidine Vidaza J9025 Y INJECTABLE Primary BCG TheraCys, Tice J9031 discontinue effective 7/1/19 Y INJECTABLE Primary BCG TheraCys, Tice J9030 effective 7/1/19 Y INJECTABLE Primary Belinostat Beleodaq J9032 Y INJECTABLE Primary Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary

Bendamustine Treanda J9033 Y INJECTABLE Primary Bendamustine HCL Belrapzo C9042 discontinue effective 6/30/19 Y INJECTABLE Primary

Bendamustine HCL Belrapzo J9036 effective 7/1/19 Y INJECTABLE Primary Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary Avastin J9035 Y INJECTABLE Primary Bevacizumab-awwb Mvasi Q5107 Y INJECTABLE Primary Bleomycin Blenoxane J9040 Y INJECTABLE Primary Blincyto J9039 Y INJECTABLE Primary Bortezomib Velcade J9041 Y INJECTABLE Primary Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary 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

Page 1 of 6 Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique Cemiplimab-rwlc Libtayo C9399 Y INJECTABLE Primary Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary Cemiplimab-rwlc Libtayo C9044 Y INJECTABLE Primary Erbitux J9055 Y INJECTABLE Primary Cisplatin Platinol J9060 Y INJECTABLE Primary 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 Darzalex J9145 Y INJECTABLE Primary Daunorubicin Cerubidine J9150 Y INJECTABLE Primary Decitabine Dacogen J0894 Y INJECTABLE Primary Degarelix Firmagon J9155 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, Doxorubicin HCL (liposomal) not Q2050 Y INJECTABLE Primary otherwise specified Durvalumab Imfinzi J9173 Y INJECTABLE Primary 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

Page 2 of 6 Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique Gemcitabine HCL - NACL Infugem J3490 Y INJECTABLE Primary Gemcitabine HCL - NACL Infugem J9999 Y INJECTABLE Primary 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 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 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, Leuprolide J1950 Y INJECTABLE Primary Acetate Leuprolide Acetate Eligard, Lupron Depot, Lupron, Leuprolide J9217 Y INJECTABLE Primary Acetate Leuprolide Acetate Eligard, Lupron Depot, Lupron, Leuprolide J9218 Y INJECTABLE Primary Acetate Levoleucovorin Fusilev J0641 Y INJECTABLE Primary Levoleucovorin Khapzory J3490 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

Page 3 of 6 Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique -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 Portrazza J9295 Y INJECTABLE Primary Nelarabine Arranon J9261 Y INJECTABLE Primary Opdivo J9299 Y INJECTABLE Primary Gazyva J9301 Y INJECTABLE Primary Octreotide depot Sandostatin J2353 Y INJECTABLE Primary Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary Arzerra J9302 Y INJECTABLE Primary 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 Vectibix J9303 Y INJECTABLE Primary Pegaspargase Oncaspar J9266 Y INJECTABLE Primary 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 Keytruda J9271 Y INJECTABLE Primary Pemetrexed Alimta J9305 Y INJECTABLE Primary Pentostatin Nipent J9268 Y INJECTABLE Primary Perjeta J9306 Y INJECTABLE Primary Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary Pralatrexate Folotyn J9307 Y INJECTABLE Primary Cyramza J9308 Y INJECTABLE Primary Rituxan J9312 Y INJECTABLE Primary Rituximab-abbs Truxima C9399 Y INJECTABLE Primary Rituximab-abbs Truxima J3490 Y INJECTABLE Primary

Page 4 of 6 Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique Rituximab-abbs Truxima J3590 Y INJECTABLE Primary Rituximab-abbs Truxima J9999 Y INJECTABLE Primary Rituximab-abbs Truxima Q5115 effective 7/1/19 Y INJECTABLE Primary Rituximab and Hyaluronidase Rituxan Hycela J9311 Y INJECTABLE Primary Human Romidepsin Istodax J9315 Y INJECTABLE Primary Sylvant J2860 Y INJECTABLE Primary Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary Streptozocin Zanosar J9320 Y INJECTABLE Primary Tagraxofusp-erzs Elzonris C9049 effective 7/1/19 Y INJECTABLE Primary Tagraxofusp-erzs Elzonris C9399 Y INJECTABLE Primary Tagraxofusp-erzs Elzonris J9999 Y INJECTABLE Primary Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary Temozolomide - inj Temodar J9328 Y INJECTABLE Primary 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, excluding biosimilars Herceptin J9355 Y INJECTABLE Primary

Trastuzumab-dkst Ogiviri J3490 Y INJECTABLE Primary Trastuzumab-dkst Ogiviri J3590 Y INJECTABLE Primary Trastuzumab-dkst Ogiviri J9999 Y INJECTABLE Primary Trastuzumab-dkst Ogiviri Q5114 effective 7/1/19 Y INJECTABLE Primary Trastuzumab-dttb Ontruzant J3490 Y INJECTABLE Primary Trastuzumab-dttb Ontruzant J3590 Y INJECTABLE Primary Trastuzumab-dttb Ontruzant Q5112 effective 7/1/19 Y INJECTABLE Primary Trastuzumab-pkrb Herzuma J3490 Y INJECTABLE Primary Trastuzumab-pkrb Herzuma J3590 Y INJECTABLE Primary Trastuzumab-pkrb Herzuma Q5113 effective 7/1/19 Y INJECTABLE Primary Trastuzumab-qyyp Trazimera J3490 Y INJECTABLE Primary

Page 5 of 6 Administration Primary Alt Descriptions HCPCS Codes HPP Drug Class Technique Trastuzumab-qyyp Trazimera J3590 Y INJECTABLE Primary Trastuzumab and hyaluronidase- Herceptin Hylecta C9399 Y INJECTABLE Primary oysk Trastuzumab and hyaluronidase- Herceptin Hylecta J9999 Y INJECTABLE Primary oysk Trastuzumab and hyaluronidase- Herceptin Hylecta J9356 effective 7/1/19 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 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 Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive Octreotide depot Sandostatin J2353 Y INJECTABLE Supportive Octreotide non-depot Sandostatin J2354 Y INJECTABLE Supportive Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic Pamidronate Disodium Aredia J2430 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

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