WIXLIB

HPHC Chemotherapy HCPCS J-CodesList– Prior Authorization RequiredCopyright 2020 Oncology Analytics, Inc. All rights reserved.

HCPCSJ CodeJ9354J9015J0207J0185J9017HCPCS DescriptionAdo-trastuzumab emt inj, 1MGAldesleukin inj, 1 EAAmifostine, 500 MGInj aprepitant, 1 mgArsenic trioxide inj, 1 MGJ9019Erwinaze inj, 1000 IUJ9022J9023J9025J9030J9032J9033J9034Inj atezolizumab, 10 mgInjection avelumab, 10 mgAzacitidine inj, 1 MGBcg live intravesical, 1 mgBelinostat inj, 10 MGBendamustine inj, 1 MGbendeka, 1 mgJ9036Generic NameAdo-Trastuzumab EmtansineKADCYLA 160 MG VIALAldesleukinPROLEUKIN 22 MILLION UNITS VLAmifostine CrystallineETHYOL 500 MG VIALAprepitantCINVANTI 130 MG/18 ML VIALArsenic TrioxideTRISENOX 12 MG/6 ML VIALAsparaginase(Erwinia Chrysanthemi)AtezolizumabERWINAZE 10,000 UNITS VIALAvelumabBAVENCIO 200 MG/10 ML VIALAzacitidineVIDAZA 100 MG VIALBCG LiveTHERACYS 81 MG VIALBelinostatBELEODAQ 500 MG VIALBendamustine HclTREANDA 45 MG/0.5 ML VIALBendamustine HclBENDEKA 100 MG/4 ML VIALBendamustine HclBENDAMUSTINE 100 MG/4 MLVIALBevacizumabAVASTIN 400 MG/16 ML VIALBevacizumab-AwwbMVASI 400 MG/16 ML VIALBevacizumab-BvzrZIRABEVBleomycin SulfateBLEOMYCIN SULFATE 30U VIALBlinatumomabBLINCYTO 35MCG VIAL STABILIZERBortezomibVELCADE 3.5 MG VIALBortezomibBORTEZOMIB 3.5 MG VIALBrentuximab VedotinADCETRIS 50 MG VIALBelrapzo inj, 1 mab inj, 10 MGMvasi inj, 10 mgInj., zirabev, 10 mgBleomycin sulfate inj, 15UNITSBlinatumomab inj, 1 MCGBortezomib inj, 0.1 MGInj bortezomib nos, 0.1 mgBrentuximab vedotin inj, 1 MGLatest Label NameCopyright 2020 Oncology Analytics, Inc. All rights reserved.TECENTRIQ 840 MG/14 ML VIAL

J9027J9057J9100J9098J0850J9130J9120J9145Busulfan inj, 1 MGCabazitaxel inj, 1 MGCalaspargase pegol-mknl inj,10 unitsCarboplatin inj, 50 MGCarfilzomib inj, 1 MGCarmustine inj, 100 MGChemotherapy drugCetuximab inj, 10 MGCisplatin inj, 10 MGCladribine inj, 1 MGClofarabine inj, 1 MGCopanlisib inj, 1 mgCytarabine HCl inj, 100 MGCytarabine liposome inj, 10MGCytomegalovirus imm iv, 1VIALDacarbazine inj, 100 MGDactinomycin inj, 0.5 MGInj daratumumab, 10 fied biologicsDarbepoetin alfa non-esrd, 1MCGDaunorubicin citrate inj, 10MGDaunorubicin inj, 10 MGInj daunorubicin cytarabine, 12.27 mgDecitabine inj, 1 MGDegarelix inj, 1 MGDenileukin diftitox inj, 300MCGBusulfanBUSULFEX 60 MG/10 ML VIALCabazitaxelJEVTANA 60 MG/1.5 ML KITCalaspargase Pegol-MknlASPARLAS 3,750 UNIT/5 ML VIALCarboplatinPARAPLATIN 600 MG/60 ML VIALCarfilzomibKYPROLIS 60 MG VIALCarmustineCARMUSTINE 100 MG VIALCemiplimab-RwlcLIBTAYO 350 MG/7 ML VIALCetuximabERBITUX 200 MG/100 ML VIALCisplatinPLATINOL-AQ 1 MG/ML VIALCladribineLEUSTATIN 10 MG/10 ML VIALClofarabineCLOLAR 20 MG/20 ML VIALCopanlisib Di-HclALIQOPA 60 MG VIALCytarabineTARABINE PFS 20 MG/ML VIALCytarabine Liposome/PFDEPOCYT 50 MG/5 ML VIALCytomegalovirus Immune Globulin CYTOMEGALOVIRUS IMMUNE(Human)GLOBDacarbazineDTIC-DOME IV 200 MG VIALDactinomycinDACTINOMYCIN 0.5 MG VIALDaratumumabDARZALEX 400 MG/20 ML VIALDaratumumab-Hyaluronidase-FihjDARZALEX FASPRO 1,800MG30,000Darbepoetin AlfaARANESP 60 MCG/ML VIALDaunorubicin Citrate LiposomalDAUNOXOME 50 MG (2 MG/ML)VIALDaunorubicin HclDAUNORUBICIN 50 MG/10 ML OS 44 MG-100 MG VIALDegarelix AcetateFIRMAGON 80 MG VIALDenileukin DiftitoxONTAK 150 MCG/ML VIALCopyright 2020 Oncology Analytics, Inc. All rights reserved.DECITABINE 50 MG VIAL

J0897J0897J1190J9171J1260J9000Denosumab inj, 1 MGDenosumab inj, 1 MGDexrazoxane HCl inj, 250 MGDocetaxel inj, 1 MGDolasetron mesylate, 10 MGDoxorubicin HCl inj, 10 MGQ2049Imported lipodox inj, 10 MGQ2050Doxorubicin inj, 10 MGJ9173J9176Durvalumab inj, 10 mgInj elotuzumab, 1 mgJ9177J9178J0885Q5106J9179J9181J9181Epirubicin HCl inj, 2 MGEpoetin alfa non-esrd, 1000UNITSInj Retacrit non-esrd use, 1000unitsEribulin mesylate inj, 0.1 MGEtoposide inj, 10 MGEtoposide inj, 10 MGJ9999J1442Q5110Q5101J9200J1453J1454Filgrastim g-csf inj, 1 MCGNivestym, 1 mcgZarxio inj, 1 MCGFloxuridine inj, 500 MGFosaprepitant inj, 1 MGInj fosnetupitant palonoset,0.25 MGJ9395J1560Fulvestrant inj, 25 MGInjection, gamma globulin,intramuscular, over 10 ccDenosumabXGEVA 120 MG/1.7 ML VIALDenosumabPROLIADexrazoxane HclZINECARD 500 MG VIALDocetaxelTAXOTERE 80 MG/4 ML VIALDolasetron MesylateANZEMET 20 MG/ML VIALDoxorubicin HclRUBEX 50 MG VIALDoxorubicin Hcl PegylatedLiposomalDoxorubicin Hcl PegylatedLiposomalLIPODOX 50 2 MG/ML VIALDurvalumabIMFINZI 500 MG/10 ML VIALElotuzumabEMPLICITI 400 MG VIALEnfortumab Vedotin-EjfvPADCEVEpirubicin HclEPIRUBICIN HCL 50 MG VIALEpoetin AlfaPROCRIT 40,000 UNITS/ML VIALEpoetin Alfa-EpbxRETACRIT 40,000 UNIT/ML VIALEribulin MesylateHALAVEN 1 MG/2 ML VIALEtoposideVEPESID 20 MG/ML VIALEtoposide PhosphateETOPOPHOS 100 MG VIALFam-Trastuzumab STYM 480 MCG/1.6 ML VIALFilgrastim-SndzZARXIO 480 MCG/0.8 ML SYRINGEFloxuridineFUDR 500 MG VIALFosaprepitant DimeglumineEMEND 150 MG VIALFosnetupitant ChlorideHcl/Palonosetron HclFulvestrantAKYNZEO 235-0.25 MG VIALGamma Globulin 10 Cc InjGamaSTAN S/DCopyright 2020 Oncology Analytics, Inc. All rights reserved.DOXORUBICIN LIPOSOME50MG/25MLNEUPOGEN 480 MCG/1.6 ML VIALFULVESTRANT 250 MG/5 MLSYRNG

J9201Gemcitabine HCl inj, 200 citabine HCl inj, 200 MGGemtuzumab ozogamicin, 0.1mgGoserelin acetate implant, 3.6MGInj granisetronxr, 0.1 mgVantas implant, 50 MGIdarubicin HCl inj, 5 MGIfosfamide inj, 1 GMInjection, immune globulin,intravenous, non-lyophilized(e.g., liquid), not otherwisespecified, 500 mgUnclassified biologicsJ1566Immune globulin powder, 500MGJ1555Inj cuvitru, 100 mgJ1556Imm glob bivigam inj, 500 MGJ1561Gamunex-c/gammaked, 500MGJ1569Gammagard liquid inj, 500 MGJ1568Octagam inj, 500 MGJ1557Gammaplex inj, 500 MGJ1566Immune globulin powder, 500MGJ1557Gammaplex inj, 500 MGGemcitabine HclGEMZAR 200 MG VIALGemcitabine Hcl In 0.9 % SodiumChlorideGemtuzumab OzogamicinINFUGEM 2,200 MG/220 ML BAGGoserelin AcetateZOLADEX 3.6 MG IMPLANT SYRNGranisetronSUSTOL 10 MG/0.4 ML SYRINGEHistrelin AcetateVANTAS 50 MG KITIdarubicin HclIDARUBICIN PFS 5 MG/5 ML VIALIfosfamideIFOSFAMIDE 3 GM/60 ML VIALImmune GlobulinASCENIVImmune ucose/Iga 0 To 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Glycine/IgaGreater Than 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Glycine/IgaGreater Than 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Glycine/IgaGreater Than 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Glycine/IgaGreater Than 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Maltose/IgaGreater Than 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Sorbitol/Glycin/Iga 0 To 50 Mcg/MlImmuneGlobulin,Gamm(Igg)/Sucrose/IgaGreater Than 50 Mcg/MlImmune Globulin,Gamma(Igg)/Glycine/Iga 0 To 50 Mcg/MlGAMMAGARD S-D 5 GM VL W/SETCopyright 2020 Oncology Analytics, Inc. All rights reserved.MYLOTARG 4.5 MG VIALCUVITRU 8 GRAM/ 40 ML VIALBIVIGAM LIQUID 10% VIALGAMUNEX 10% VIALGAMMAGARD LIQUID 10% VIALOCTAGAM 5% VIALGAMMAPLEX 5 GRAM/100 ML VIALCARIMUNE NF 6 GM VIALGAMMAPLEX 5 GRAM/50 ML VIAL

J1459Ivig privigen inj, 500 MGJ1559Hizentra inj, 100 MGJ1572J1561J1460Flebogamma inj, 500 MGGamunex-c/gammaked, 500MGGamma globulin inj, 1 CCJ1575Hyqvia immuneglobulin, 100MGJ1460Gamma globulin inj, 1 CCJ1561Gamunex-c/gammaked, ed biologicsInjection, immune globulin,intravenous, non-lyophilized(e.g., liquid), not otherwisespecified, 500 mgInotuzumab ozogam inj, 0.1mgIodine i-131 iobenguane tx,1millicurieIpilimumab inj, 1 MGIrinotecan inj, 20 MGirinotecan liposome inj, 1 mgJ9999J9207Ixabepilone inj, 1 MGA9543Y90 ibritumomab rx, 40millicuriesJ1930Immune Globulin,Gamma(Igg)/Proline/Iga 0 To 50 Mcg/MlImmune Globulin,Gamma(Igg)/Proline/Iga 0 To 50 Mcg/MlImmune Globulin,Gamma(Igg)/Sorbitol/Iga 0 To 50 Mcg/MlImmune Globulin,GammaCaprylate (Igg)Immune Globulin,Gamma(Igg)PRIVIGEN 10% VIALImmune Globulin,Gamma(Igg)Human/Hyaluronidase, Globulin,Gamma(Igg)/Glycine/IgaAverage 46 Mcg/MlImmune Globulin,Gamma(Igg)Hipp Human/MaltoseImmune Globulin,Gamma(Igg)-IfasHuman/GlycineHYQVIA 5 GM-400 UNIT PACKInotuzumab OzogamicinBESPONSA 0.9 MG VIALIobenguane Iodine 131AZEDRA THERAPEUTIC VIALIpilimumabYERVOY 50 MG/10 ML VIALIrinotecan HclIRINOTECAN HCL 500 MG/25 ML VLIrinotecan LiposomalONIVYDE 43 MG/10 ML VIALIsatuximab-IrfcSARCLISAIxabepiloneIXEMPRA 45 MG KITKit For Prep Yttrium90/IbritumomabTiuxetan/Albumin HumanLanreotide AcetateZEVALIN Y-90 VIALLeuprolide AcetateLUPRON DEPOT-PED 30 MG 3MOKITLeuprolide AcetateLUPRON DEPOT-PED 7.5 MG KITLanreotide inj, 1 MGJ1950J9217Leuprolide acetate, 3.75 MGLeuprolide acetate suspnsion,7.5 MGCopyright 2020 Oncology Analytics, Inc. All rights reserved.HIZENTRA 4 GRAM/20 ML VIALFLEBOGAMMA DIF 5% VIALGAMMAKEDIMMUNE SERUM GLOBULIN VIALGAMASTAN VIALGAMUNEX-C 5 GRAM/50 ML VIALCUTAQUIG 16.5% (8 G/48 ML) VLPANZYGA 10% (5 G/50 ML) VIALSOMATULINE DEPOT 90 MG/0.3ML

J9217J9218J9219J0642J0641Leuprolide acetate suspnsion,7.5 MGLeuprolide acetate inj, 1 MGLeuprolide acetate implant, 65MGInjection levoleucovorin, 1 mgLevoleucovorin inj, 0.5 fied biologicsLutetium lu 177 dotatat ther,1 millicurieLymphocyte immune globulin,250 MGMechlorethamine HCl inj, 10MGMelphalan hydrochl inj, 50MGMelphalan hydrochl inj, 50MGMitomycin inj, 5 oxantrone hydrochl, 5 MGChemotherapy drugInj moxetumomab pasudotoxtdfk, 0.01 mgnecitumumab injection, 1 mgNelarabine inj, 50 MGNivolumab inj, 1 MGObinutuzumab inj, 10 MGOctreotide non-depot inj, 25MCGJ2353Leuprolide AcetateELIGARD 7.5 MG SYRINGE KITLeuprolide AcetateLUPRON 4-WK 1 MG/0.2 ML KITLeuprolide Acetate/Lidocaine HclVIADUR IMPLANT KITLevoleucovorinKHAPZORY 300 MG VIALLevoleucovorin CalciumLEVOLEUCOVORIN 50 MG VIALLurbinectedinZEPZELCALuspatercept-AamtREBLOZYL 75 MG VIALLutetium Lu 177 DotatateLUTATHERA 370 MBQ (10 hlorethamine HclATGAM 50 MG/ML AMPULMelphalan HclMELPHALAN HCL 50 MG VIALMelphalan Hcl/Betadex SulfobutylEther SodiumMitomycinEVOMELA 50 MG VIALMitomycin GelJELMYTOMitoxantrone HclNOVANTRONE 2 MG/ML VIALMogamulizumab-KpkcPOTELIGEO 20 MG/5 ML VIALMoxetumomab Pasudotox-TdfkLUMOXITI 1 MG VIALNecitumumabPORTRAZZA 800 MG/50 ML VIALNelarabineARRANON 250 MG/50 ML VIALNivolumabOPDIVO 40 MG/4 ML VIALObinutuzumabGAZYVA 1,000 MG/40 ML VIALOctreotide AcetateSANDOSTATIN 1 MG/ML VIALOctreotide Acetate, MicrospheresSANDOSTATIN LAR DEPOT 30 MGVLOfatumumabARZERRA 100 MG/5 ML VIALOlaratumabLARTRUVO 500 MG/50 ML VIALOmacetaxine MepesuccinateSYNRIBO 3.5 MG/ML VIALOctreotide depot inj, 1 MGJ9302J9285J9262Ofatumumab inj, 10 MGInj olaratumab, 10 mgomacetaxine mep inj, 0.01 mgCopyright 2020 Oncology Analytics, Inc. All rights reserved.MUSTARGEN 10 MG VIALMUTAMYCIN 5 MG VIAL