Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2014
`
`HCPCS Code
`90371
`90375
`90376
`90385
`90585
`90586
`90632
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`50 MCG
`50 MG
`1 EACH
`1 ML
`
`Payment Limit
`117.379
`247.567
`237.823
`34.662
`121.959
`121.959
`49.539
`
`90654
`
`Flu vaccine, intradermal, no preserv
`
`0.1 ML
`
`90656
`
`Flu vaccine no preserv 3 yo & >, im
`
`0.50 ML
`
`90657
`
`90661
`
`90662
`90670
`
`90672
`90675
`
`90685
`
`90686
`
`Flu vaccine, 6-35 mo, im
`
`0.25 ML
`
`Flu vaccine, no preserv, 3 +, im, cell
`cultures
`
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 13 val im
`
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`1 ML
`
`Flu vac no prsv 4 val 6-35 m
`
`0.25 mL
`
`Flu vac no prsv 4 val 3 yrs+
`
`0.5 ml
`
`90687
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`0.25 ML
`
`90688
`90691
`90703
`90714
`90715
`90732
`90733
`90740
`90743
`90744
`90746
`90747
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`J0133
`J0135
`J0150
`J0151
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0400
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`
`Flu vaccine, 3 +, IM, 4 val
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Inj Adenosine Diag 1mg
`Adrenalin epinephrine inject
`Aflibercept injection (ophthalmic)
`Agalsidase beta injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alglucosidase alfa injection
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amphotericin B
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Aripiprazole injection
`Inj aripriprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`PenG benzathine/procaine inj
`Penicillin g benzathine inj
`Bivalirudin
`Injection,onabotulinumtoxinA
`AbobotulinumtoxinA
`Inj, rimabotulinumtoxinB
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`40 MCG
`1 DOSE
`1 DOSE
`20 MCG
`40 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`6 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`500 MG
`250 MG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`1 MG
`20 MG
`0.25 MG
`1 MG
`500 MG
`0.01 MG
`100 MG
`10 MG
`50 MCG
`20 MG
`1 MG
`10 MG
`20 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`1 MG
`1 UNIT
`5 Unit
`100 UNITS
`
`18.918
`
`14.096
`
`6.022
`
`21.666
`
`33.374
`153.963
`
`25.736
`223.778
`
`23.900
`
`17.984
`
`9.134
`
`16.844
`68.549
`41.265
`21.955
`33.316
`77.847
`106.492
`119.415
`24.216
`24.216
`59.708
`119.415
`0.361
`1.823
`2.224
`1.747
`2.012
`14.040
`12.143
`0.410
`32.248
`739.170
`2.191
`0.059
`570.940
`5.721
`2.134
`0.132
`980.500
`152.350
`310.717
`42.400
`41.644
`206.633
`153.640
`4.109
`3.975
`1.268
`3.978
`16.218
`10.405
`16.829
`1.250
`1.819
`0.688
`2.980
`0.645
`3.873
`2.341
`0.050
`29.375
`162.796
`76.288
`2716.177
`3.809
`39.484
`41.281
`20.379
`4.923
`6.287
`3.421
`5.560
`7.434
`11.302
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`18.918
`
`14.096
`
`6.022
`
`21.666
`
`33.374
`153.963
`
`25.736
`
`23.900
`
`17.984
`
`9.134
`
`16.844
`
`77.847
`
`119.415
`24.216
`24.216
`59.708
`119.415
`
`95
`95
`95
`
`10.280
`21.850
`35.800
`
`95
`95
`
`215.180
`79.800
`
`Medac Exhibit 2057
`Koios Pharmaceuticals v. Medac
`IPR2016-01370
`Page 00001
`
`

`

`J0588
`J0592
`J0594
`J0595
`J0597
`
`Incobotulinumtoxin A
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`C-1 esterase, berinert
`
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`10 UNITS
`
`4.480
`3.063
`28.937
`1.756
`37.635
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2015
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`HCPCS Code
`90814.2069
`90825.07831
`90835.94972
`90846.82113
`90857.69255
`90868.56396
`90879.43537
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`
`HCPCS Code Dosage
`2 ML
`150 IU
`150 IU
`51 MCG
`51 MG
`2 EACH
`2 ML
`
`Payment Limit
`123.735
`124.263
`124.792
`125.320
`125.848
`126.376
`126.905
`
`90890.30679
`
`Flu vaccine, intradermal, no preserv
`
`0.1 ML
`
`127.433
`
`90901.1782
`
`Flu vaccine no preserv 3 yo & >, im
`
`0.50 ML
`
`127.961
`
`90912.04961
`
`Flu vaccine, 6-35 mo, im
`
`0.25 ML
`
`128.490
`
`90922.92102
`
`Flu vaccine, no preserv, 3 +, im, cell
`cultures
`
`90933.79244
`90944.66385
`
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 13 val im
`
`90955.53526
`90966.40667
`
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`2 ML
`
`129.018
`
`129.546
`130.074
`
`130.603
`131.131
`
`90977.27809
`
`Flu vac no prsv 4 val 6-35 m
`
`0.25 mL
`
`131.659
`
`90988.1495
`
`Flu vac no prsv 4 val 3 yrs+
`
`0.5 ml
`
`132.187
`
`90999.02091
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`0.25 ML
`
`132.716
`
`91009.89232
`91020.76374
`91031.63515
`91042.50656
`91053.37798
`91064.24939
`91075.1208
`91085.99221
`91096.86363
`91107.73504
`91118.60645
`91129.47786
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`J0133
`J0135
`J0150
`J0151
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0400
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`
`Flu vaccine, 3 +, IM, 4 val
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Inj Adenosine Diag 1mg
`Adrenalin epinephrine inject
`Aflibercept injection (ophthalmic)
`Agalsidase beta injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alglucosidase alfa injection
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amphotericin B
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Aripiprazole injection
`Inj aripriprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`PenG benzathine/procaine inj
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`41 MCG
`1 DOSE
`1 DOSE
`60 MCG
`80 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`6 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`500 MG
`250 MG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`39 MG
`58 MG
`0.25 MG
`999 MG
`1498 MG
`0.01 MG
`80 MG
`170 MG
`51 MCG
`20 MG
`1 MG
`10 MG
`20 MG
`1 MG
`100,000 UNITS
`
`133.244
`133.772
`134.300
`134.829
`135.357
`135.885
`136.414
`136.942
`137.470
`137.998
`138.527
`139.055
`139.583
`140.111
`140.640
`141.168
`141.696
`142.224
`142.753
`143.281
`143.809
`144.338
`144.866
`145.394
`145.922
`146.451
`146.979
`147.507
`148.035
`148.564
`149.092
`149.620
`150.148
`150.677
`151.205
`151.733
`152.262
`152.790
`153.318
`153.846
`154.375
`154.903
`155.431
`155.959
`156.488
`157.016
`157.544
`158.072
`158.601
`159.129
`159.657
`160.186
`160.714
`161.242
`161.770
`162.299
`162.827
`163.355
`163.883
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`74.164
`
`76.453
`
`78.742
`
`81.030
`
`83.319
`85.607
`
`87.896
`90.185
`
`92.473
`
`94.762
`
`97.050
`
`99.339
`101.628
`103.916
`106.205
`108.493
`110.782
`113.071
`115.359
`117.648
`119.937
`122.225
`124.514
`
`95
`95
`95
`
`95
`95
`
`160.163
`170.589
`181.015
`191.441
`201.868
`212.294
`222.720
`233.146
`243.573
`253.999
`264.425
`274.852
`285.278
`295.704
`
`Page 00002
`
`

`

`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`
`Penicillin g benzathine inj
`Bivalirudin
`Injection,onabotulinumtoxinA
`AbobotulinumtoxinA
`Inj, rimabotulinumtoxinB
`Incobotulinumtoxin A
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`C-1 esterase, berinert
`
`100,000 UNITS
`2 MG
`9 UNIT
`13 UNIT
`101 UNITS
`2 UNIT
`0.1 MG
`1 MG
`1 MG
`11 UNITS
`
`164.412
`164.940
`165.468
`165.996
`166.525
`167.053
`167.581
`168.110
`168.638
`169.166
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2016
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`HCPCS Code
`91140.34928
`91151.22069
`91162.0921
`91172.96352
`91183.83493
`91194.70634
`91205.57775
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`
`HCPCS Code Dosage
`3 ML
`150 IU
`150 IU
`52 MCG
`52 MG
`3 EACH
`3 ML
`
`Payment Limit
`169.694
`170.223
`170.751
`171.279
`171.807
`172.336
`172.864
`
`91216.44917
`
`Flu vaccine, intradermal, no preserv
`
`0.1 ML
`
`173.392
`
`91227.32058
`
`Flu vaccine no preserv 3 yo & >, im
`
`0.50 ML
`
`173.920
`
`91238.19199
`
`Flu vaccine, 6-35 mo, im
`
`0.25 ML
`
`174.449
`
`91249.0634
`
`Flu vaccine, no preserv, 3 +, im, cell
`cultures
`
`91259.93482
`91270.80623
`
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 13 val im
`
`91281.67764
`91292.54905
`
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`3 ML
`
`174.977
`
`175.505
`176.034
`
`176.562
`177.090
`
`91303.42047
`
`Flu vac no prsv 4 val 6-35 m
`
`0.25 mL
`
`177.618
`
`91314.29188
`
`Flu vac no prsv 4 val 3 yrs+
`
`0.5 ml
`
`178.147
`
`91325.16329
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`0.25 ML
`
`178.675
`
`91336.03471
`91346.90612
`91357.77753
`91368.64894
`91379.52036
`91390.39177
`91401.26318
`91412.13459
`91423.00601
`91433.87742
`91444.74883
`91455.62024
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`J0133
`J0135
`J0150
`J0151
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0400
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`
`Flu vaccine, 3 +, IM, 4 val
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Inj Adenosine Diag 1mg
`Adrenalin epinephrine inject
`Aflibercept injection (ophthalmic)
`Agalsidase beta injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alglucosidase alfa injection
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amphotericin B
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Aripiprazole injection
`Inj aripriprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`42 MCG
`1 DOSE
`1 DOSE
`100 MCG
`120 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`6 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`500 MG
`250 MG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`77 MG
`96 MG
`0.25 MG
`1997 MG
`2496 MG
`0.01 MG
`260 MG
`350 MG
`52 MCG
`20 MG
`
`179.203
`179.731
`180.260
`180.788
`181.316
`181.844
`182.373
`182.901
`183.429
`183.958
`184.486
`185.014
`185.542
`186.071
`186.599
`187.127
`187.655
`188.184
`188.712
`189.240
`189.768
`190.297
`190.825
`191.353
`191.882
`192.410
`192.938
`193.466
`193.995
`194.523
`195.051
`195.579
`196.108
`196.636
`197.164
`197.692
`198.221
`198.749
`199.277
`199.806
`200.334
`200.862
`201.390
`201.919
`202.447
`202.975
`203.503
`204.032
`204.560
`205.088
`205.616
`206.145
`206.673
`207.201
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`126.802
`
`129.091
`
`131.380
`
`133.668
`
`135.957
`138.245
`
`140.534
`142.823
`
`145.111
`
`147.400
`
`149.688
`
`151.977
`154.266
`156.554
`158.843
`161.132
`163.420
`165.709
`167.997
`170.286
`172.575
`174.863
`177.152
`
`95
`95
`95
`
`95
`95
`
`306.130
`316.557
`326.983
`337.409
`347.835
`358.262
`368.688
`379.114
`389.540
`399.967
`410.393
`420.819
`431.246
`441.672
`
`Page 00003
`
`

`

`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`PenG benzathine/procaine inj
`Penicillin g benzathine inj
`Bivalirudin
`Injection,onabotulinumtoxinA
`AbobotulinumtoxinA
`Inj, rimabotulinumtoxinB
`Incobotulinumtoxin A
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`C-1 esterase, berinert
`
`1 MG
`10 MG
`20 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`3 MG
`17 UNIT
`21 UNIT
`102 UNITS
`3 UNIT
`0.1 MG
`1 MG
`1 MG
`12 UNITS
`
`207.730
`208.258
`208.786
`209.314
`209.843
`210.371
`210.899
`211.427
`211.956
`212.484
`213.012
`213.540
`214.069
`214.597
`215.125
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2017
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`HCPCS Code
`91466.49166
`91477.36307
`91488.23448
`91499.1059
`91509.97731
`91520.84872
`91531.72013
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`
`HCPCS Code Dosage
`4 ML
`150 IU
`150 IU
`53 MCG
`53 MG
`4 EACH
`4 ML
`
`Payment Limit
`215.654
`216.182
`216.710
`217.238
`217.767
`218.295
`218.823
`
`91542.59155
`
`Flu vaccine, intradermal, no preserv
`
`0.1 ML
`
`219.351
`
`91553.46296
`
`Flu vaccine no preserv 3 yo & >, im
`
`0.50 ML
`
`219.880
`
`91564.33437
`
`Flu vaccine, 6-35 mo, im
`
`0.25 ML
`
`220.408
`
`91575.20578
`
`Flu vaccine, no preserv, 3 +, im, cell
`cultures
`
`91586.0772
`91596.94861
`
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 13 val im
`
`91607.82002
`91618.69143
`
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`4 ML
`
`220.936
`
`221.465
`221.993
`
`222.521
`223.049
`
`91629.56285
`
`Flu vac no prsv 4 val 6-35 m
`
`0.25 mL
`
`223.578
`
`91640.43426
`
`Flu vac no prsv 4 val 3 yrs+
`
`0.5 ml
`
`224.106
`
`91651.30567
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`0.25 ML
`
`224.634
`
`91662.17709
`91673.0485
`91683.91991
`91694.79132
`91705.66274
`91716.53415
`91727.40556
`91738.27697
`91749.14839
`91760.0198
`91770.89121
`91781.76263
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`J0133
`J0135
`J0150
`J0151
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0400
`J0401
`J0456
`
`Flu vaccine, 3 +, IM, 4 val
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Inj Adenosine Diag 1mg
`Adrenalin epinephrine inject
`Aflibercept injection (ophthalmic)
`Agalsidase beta injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alglucosidase alfa injection
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amphotericin B
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Aripiprazole injection
`Inj aripriprazole ext rel 1mg
`Azithromycin
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`43 MCG
`1 DOSE
`1 DOSE
`140 MCG
`160 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`6 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`500 MG
`250 MG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`115 MG
`134 MG
`0.25 MG
`2995 MG
`3494 MG
`
`225.162
`225.691
`226.219
`226.747
`227.275
`227.804
`228.332
`228.860
`229.389
`229.917
`230.445
`230.973
`231.502
`232.030
`232.558
`233.086
`233.615
`234.143
`234.671
`235.199
`235.728
`236.256
`236.784
`237.313
`237.841
`238.369
`238.897
`239.426
`239.954
`240.482
`241.010
`241.539
`242.067
`242.595
`243.123
`243.652
`244.180
`244.708
`245.237
`245.765
`246.293
`246.821
`247.350
`247.878
`248.406
`248.934
`249.463
`249.991
`250.519
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`179.440
`
`181.729
`
`184.018
`
`186.306
`
`188.595
`190.883
`
`193.172
`195.461
`
`197.749
`
`200.038
`
`202.326
`
`204.615
`206.904
`209.192
`211.481
`213.770
`216.058
`218.347
`220.635
`222.924
`225.213
`227.501
`229.790
`
`95
`95
`95
`
`452.098
`462.524
`472.951
`483.377
`493.803
`504.229
`514.656
`525.082
`535.508
`545.934
`
`Page 00004
`
`

`

`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`PenG benzathine/procaine inj
`Penicillin g benzathine inj
`Bivalirudin
`Injection,onabotulinumtoxinA
`AbobotulinumtoxinA
`Inj, rimabotulinumtoxinB
`Incobotulinumtoxin A
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`C-1 esterase, berinert
`
`0.01 MG
`440 MG
`530 MG
`53 MCG
`20 MG
`1 MG
`10 MG
`20 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`4 MG
`25 UNIT
`29 UNIT
`103 UNITS
`4 UNIT
`0.1 MG
`1 MG
`1 MG
`13 UNITS
`
`95
`95
`
`556.361
`566.787
`577.213
`587.640
`
`251.047
`251.576
`252.104
`252.632
`253.161
`253.689
`254.217
`254.745
`255.274
`255.802
`256.330
`256.858
`257.387
`257.915
`258.443
`258.971
`259.500
`260.028
`260.556
`261.085
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2018
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`HCPCS Code
`91792.63404
`91803.50545
`91814.37686
`91825.24828
`91836.11969
`91846.9911
`91857.86251
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`
`HCPCS Code Dosage
`5 ML
`150 IU
`150 IU
`54 MCG
`54 MG
`5 EACH
`5 ML
`
`Payment Limit
`261.613
`262.141
`262.669
`263.198
`263.726
`264.254
`264.782
`
`91868.73393
`
`Flu vaccine, intradermal, no preserv
`
`0.1 ML
`
`265.311
`
`91879.60534
`
`Flu vaccine no preserv 3 yo & >, im
`
`0.50 ML
`
`265.839
`
`91890.47675
`
`Flu vaccine, 6-35 mo, im
`
`0.25 ML
`
`266.367
`
`91901.34816
`
`Flu vaccine, no preserv, 3 +, im, cell
`cultures
`
`91912.21958
`91923.09099
`
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 13 val im
`
`91933.9624
`91944.83382
`
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`5 ML
`
`266.895
`
`267.424
`267.952
`
`268.480
`269.009
`
`91955.70523
`
`Flu vac no prsv 4 val 6-35 m
`
`0.25 mL
`
`269.537
`
`91966.57664
`
`Flu vac no prsv 4 val 3 yrs+
`
`0.5 ml
`
`270.065
`
`91977.44805
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`0.25 ML
`
`270.593
`
`91988.31947
`91999.19088
`92010.06229
`92020.9337
`92031.80512
`92042.67653
`92053.54794
`92064.41935
`92075.29077
`92086.16218
`92097.03359
`92107.90501
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`J0133
`J0135
`J0150
`J0151
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`
`Flu vaccine, 3 +, IM, 4 val
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Inj Adenosine Diag 1mg
`Adrenalin epinephrine inject
`Aflibercept injection (ophthalmic)
`Agalsidase beta injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alglucosidase alfa injection
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amphotericin B
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`44 MCG
`1 DOSE
`1 DOSE
`180 MCG
`200 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`6 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`500 MG
`250 MG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`
`271.122
`271.650
`272.178
`272.706
`273.235
`273.763
`274.291
`274.819
`275.348
`275.876
`276.404
`276.933
`277.461
`277.989
`278.517
`279.046
`279.574
`280.102
`280.630
`281.159
`281.687
`282.215
`282.743
`283.272
`283.800
`284.328
`284.857
`285.385
`285.913
`286.441
`286.970
`287.498
`288.026
`288.554
`289.083
`289.611
`290.139
`290.667
`291.196
`291.724
`292.252
`292.781
`293.309
`293.837
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`added October 2014 - see the Seasonal Influenza
`Vaccines Pricing webpage for current payment limits
`and effective dates
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`232.078
`
`234.367
`
`236.656
`
`238.944
`
`241.233
`243.521
`
`245.810
`248.099
`
`250.387
`
`252.676
`
`254.965
`
`257.253
`259.542
`261.830
`264.119
`266.408
`268.696
`270.985
`273.273
`275.562
`277.851
`280.139
`282.428
`
`95
`95
`95
`
`598.066
`608.492
`618.918
`629.345
`639.771
`
`Page 00005
`
`

`

`J0348
`J0360
`J0400
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`
`Anidulafungin injection
`Hydralazine hcl injection
`Aripiprazole injection
`Inj aripriprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`PenG benzathine/procaine inj
`Penicillin g benzathine inj
`Bivalirudin
`Injection,onabotulinumtoxinA
`AbobotulinumtoxinA
`Inj, rimabotulinumtoxinB
`Incobotulinumtoxin A
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`C-1 esterase, berinert
`
`153 MG
`172 MG
`0.25 MG
`3993 MG
`4492 MG
`0.01 MG
`620 MG
`710 MG
`54 MCG
`20 MG
`1 MG
`10 MG
`20 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`5 MG
`33 UNIT
`37 UNIT
`104 UNITS
`5 UNIT
`0.1 MG
`1 MG
`1 MG
`14 UNITS
`
`95
`95
`
`650.197
`660.623
`671.050
`681.476
`691.902
`702.328
`712.755
`723.181
`733.607
`
`294.365
`294.894
`295.422
`295.950
`296.478
`297.007
`297.535
`298.063
`298.591
`299.120
`299.648
`300.176
`300.705
`301.233
`301.761
`302.289
`302.818
`303.346
`303.874
`304.402
`304.931
`305.459
`305.987
`306.515
`307.044
`Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2014 through December 31, 2019
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q14 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effective
`dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and effect