Payment Allowance Limits for Medicare Part B Drugs
`Effective October 1, 2013 through December 31, 2013
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q13 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
`
`95
`95
`95
`95
`95
`95
`95
`95
`
`95
`95
`
`95
`
`95
`95
`95
`95
`95
`
`18.918
`17.243
`12.398
`6.022
`31.823
`95.481
`145.107
`24.596
`
`23.228
`19.409
`
`72.352
`
`119.415
`24.216
`24.216
`59.708
`119.415
`
`Added October 2013
`
`Added October 2013
`Added October 2013
`
`HCPCS Code
`90371
`90375
`90376
`90385
`90585
`90586
`90632
`90654
`90655
`90656
`90657
`90662
`90669
`90670
`90672
`90675
`90685
`90686
`90691
`90703
`90714
`90715
`90717
`90732
`90733
`90735
`90740
`90743
`90744
`90746
`90747
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`J0129
`J0130
`J0132
`
`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
`Flu vaccine, intradermal, no preserv
`Flu vaccine no preserv 6-35m, im
`Flu vaccine no preserv 3 yo & >, im
`Flu vaccine, 6-35 mo, im
`Flu vacc prsv free inc antig
`Pneumococcal vacc, 7 val im
`Pneumococcal vacc, 13 val im
`Flu vaccine 4 valent nasal
`Rabies vaccine, im
`Flu vac no prsv 4 val 6-35 m
`Flu vac no prsv 4 val 3 yrs+
`Typhoid vaccine, im
`Tetanus vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Yellow fever vaccine, sc
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Encephalitis 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 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
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`50 MCG
`50 MG
`1 EACH
`1 ML
`0.1 ML
`0.25 ML
`0.50 ML
`0.25 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.2 ml
`1 ML
`0.25 mL
`0.5 ml
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`1 ML
`40 MCG
`1 DOSE
`1 DOSE
`20 MCG
`40 MCG
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`10 MG
`10 MG
`100 MG
`
`Payment Limit
`112.029
`219.815
`216.535
`25.281
`120.914
`120.914
`49.667
`18.918
`17.243
`12.398
`6.022
`31.823
`95.481
`145.107
`24.596
`232.385
`23.228
`19.409
`62.552
`39.285
`19.474
`33.799
`75.060
`72.352
`106.492
`102.078
`119.415
`24.216
`24.216
`59.708
`119.415
`1.807
`2.216
`2.114
`1.948
`13.274
`11.721
`0.405
`23.060
`651.253
`2.652
`
`Exhibit 2234
`Page 01 of 11
`
`

`

`J0133
`J0135
`J0150
`J0152
`J0171
`J0178
`J0180
`J0207
`J0210
`J0215
`J0220
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0288
`J0289
`J0290
`J0295
`J0348
`J0360
`J0364
`J0365
`J0400
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`J0598
`J0600
`J0610
`J0630
`J0636
`
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Adenosine injection
`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
`Ampho b cholesteryl sulfate
`Amphotericin b liposome inj
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Apomorphine hydrochloride
`Aprotonin, 10,000 kiu
`Aripiprazole injection
`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
`C-1 esterase, cinryze
`Edetate calcium disodium inj
`Calcium gluconate injection
`Calcitonin salmon injection
`Inj calcitriol per 0.1 mcg
`
`5 MG
`20 MG
`6 MG
`30 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
`10 MG
`500 MG
`1.5 GM
`1 MG
`20 MG
`1 MG
`10000 KIU
`0.25 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
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`10 UNITS
`10 UNITS
`1000 MG
`10 ML
`400 UNITS
`0.1 MCG
`
`0.048
`515.891
`5.831
`109.379
`0.057
`980.500
`146.193
`298.541
`42.400
`41.644
`206.640
`153.602
`4.024
`3.986
`1.075
`1.188
`11.374
`11.415
`14.000
`15.574
`1.451
`1.661
`0.847
`3.143
`33.064
`2.646
`0.545
`3.314
`0.044
`29.554
`160.302
`74.105
`2442.922
`3.802
`38.252
`38.609
`21.023
`4.044
`5.081
`3.210
`5.453
`7.053
`10.889
`4.476
`0.989
`25.184
`1.745
`32.693
`49.335
`201.400
`1.073
`69.048
`0.371
`
`updated July 2014
`
`95
`95
`95
`95
`
`10.280
`21.850
`15.200
`35.800
`
`95
`95
`
`215.180
`79.800
`
`Exhibit 2234
`Page 02 of 11
`
`

`

`J0637
`J0638
`J0640
`J0641
`J0670
`J0690
`J0692
`J0694
`J0696
`J0697
`J0698
`J0702
`J0706
`J0712
`J0713
`J0718
`J0720
`J0725
`J0735
`J0740
`J0743
`J0744
`J0770
`J0775
`J0780
`J0795
`J0800
`J0834
`J0840
`J0850
`J0878
`J0881
`J0882
`J0885
`J0886
`J0894
`J0895
`J0897
`J1000
`J1020
`J1030
`J1040
`J1050
`J1070
`J1080
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`J1170
`J1190
`
`Caspofungin acetate
`Canakinumab injection
`Leucovorin calcium injection
`Levoleucovorin injection
`Inj mepivacaine HCL/10 ml
`Cefazolin sodium injection
`Cefepime HCl for injection
`Cefoxitin sodium injection
`Ceftriaxone sodium injection
`Sterile cefuroxime injection
`Cefotaxime sodium injection
`Betamethasone acet&sod phosp
`Caffeine citrate injection
`Ceftaroline fosamil inj
`Inj ceftazidime per 500 mg
`Certolizumab pegol inj
`Chloramphenicol sodium injec
`Chorionic gonadotropin/1000u
`Clonidine hydrochloride
`Cidofovir injection
`Cilastatin sodium injection
`Ciprofloxacin iv
`Colistimethate sodium inj
`Collagenase, clost hist inj
`Prochlorperazine injection
`Corticorelin ovine triflutal
`Corticotropin injection
`Cosyntropin cortrosyn inj
`Crotalidae poly immune fab
`Cytomegalovirus imm IV /vial
`Daptomycin injection
`Darbepoetin alfa, non-esrd
`Darbepoetin alfa, esrd use
`Epoetin alfa, non-esrd
`Epoetin alfa 1000 units ESRD
`Decitabine injection
`Deferoxamine mesylate inj
`Denosumab injection
`Depo-estradiol cypionate inj
`Methylprednisolone 20 MG inj
`Methylprednisolone 40 MG inj
`Methylprednisolone 80 MG inj
`Medroxyprogesterone acetate
`Testosterone cypionat 100 MG
`Testosterone cypionat 200 MG
`Dexamethasone sodium phos
`Inj dihydroergotamine mesylt
`Acetazolamid sodium injectio
`Digoxin injection
`Digoxin immune fab (ovine)
`Phenytoin sodium injection
`Hydromorphone injection
`Dexrazoxane HCl injection
`
`5 MG
`1 MG
`50 MG
`0.5 MG
`10 ML
`500 MG
`500 MG
`1 GM
`250 MG
`750 MG
`1 GM
`3 MG & 3 MG
`5 MG
`10 MG
`500 MG
`1 MG
`1 GM
`1000 UNITS
`1 MG
`375 MG
`250 MG
`200 MG
`150 MG
`0.01 MG
`10 MG
`1 MCG
`40 UNITS
`0.25 MG
`UP TO 1 GM
`PER VIAL
`1 MG
`1 MCG
`1 MCG
`1000 UNITS
`1000 UNITS
`1 MG
`500 MG
`1 MG
`5 MG
`20 MG
`40 MG
`80 MG
`1 MG
`100 MG
`200 MG
`1 MG
`1 MG
`500 MG
`0.5 MG
`PER VIAL
`50 MG
`4 MG
`250 MG
`
`13.345
`91.021
`4.501
`1.744
`2.432
`0.879
`2.878
`5.191
`0.741
`3.162
`1.748
`5.700
`0.517
`0.878
`1.946
`5.178
`29.460
`15.403
`21.885
`648.433
`5.694
`1.157
`12.356
`38.572
`4.073
`7.780
`3050.437
`65.444
`2349.902
`1013.869
`0.604
`3.666
`3.666
`11.222
`11.222
`34.782
`7.885
`14.153
`8.103
`2.996
`2.735
`5.302
`0.217
`4.478
`5.051
`0.121
`33.469
`26.536
`2.037
`1241.366
`0.542
`2.209
`139.651
`
`updated July 2014
`
`updated July 2014
`updated July 2014
`
`AMP-based payment limit
`
`95
`
`15.630
`
`95
`
`1.490
`
`Exhibit 2234
`Page 03 of 11
`
`

`

`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1260
`J1265
`J1267
`J1270
`J1290
`J1300
`J1325
`J1327
`J1335
`J1364
`J1380
`J1410
`J1430
`J1438
`J1440
`J1441
`J1450
`J1451
`J1453
`J1458
`J1459
`J1460
`J1557
`J1559
`J1560
`J1561
`J1566
`J1568
`J1569
`J1570
`J1571
`J1572
`J1573
`J1580
`J1600
`J1610
`J1626
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`
`Diphenhydramine hcl injectio
`Chlorothiazide sodium inj
`Dimethyl sulfoxide 50% 50 ML
`Methadone injection
`Dimenhydrinate injection
`Dipyridamole injection
`Inj dobutamine HCL/250 mg
`Dolasetron mesylate
`Dopamine injection
`Doripenem injection
`Injection, doxercalciferol
`Ecallantide injection
`Eculizumab injection
`Epoprostenol injection
`Eptifibatide injection
`Ertapenem injection
`Erythro lactobionate /500 MG
`Estradiol valerate 10 MG inj
`Inj estrogen conjugate 25 MG
`Ethanolamine oleate 100 mg
`Etanercept injection
`Filgrastim 300 mcg injection
`Filgrastim 480 mcg injection
`Fluconazole
`Fomepizole, 15 mg
`Fosaprepitant injection
`Galsulfase injection
`Inj IVIG privigen 500 mg
`Gamma globulin 1 CC inj
`Gammaplex injection
`Hizentra injection
`Gamma globulin > 10 CC inj
`Gamunex-C/Gammaked
`Immune globulin, powder
`Octagam injection
`Gammagard liquid injection
`Ganciclovir sodium injection
`Hepagam b im injection
`Flebogamma injection
`Hepagam b intravenous, inj
`Garamycin gentamicin inj
`Gold sodium thiomaleate inj
`Glucagon hydrochloride/1 MG
`Granisetron hcl injection
`Haloperidol injection
`Haloperidol decanoate inj
`Hemin, 1 mg
`Inj heparin sodium per 10 u
`Inj heparin sodium per 1000u
`Dalteparin sodium
`Inj enoxaparin sodium
`Fondaparinux sodium
`Tetanus immune globulin inj
`
`50 MG
`500 MG
`50 ML
`10 MG
`50 MG
`10 MG
`250 MG
`10 MG
`40 MG
`10 MG
`1 MCG
`1 MG
`10 MG
`0.5 MG
`5 MG
`500 MG
`500 MG
`10 MG
`25 MG
`100 MG
`25 MG
`300 MCG
`480 MCG
`200 MG
`15 MG
`1 MG
`1 MG
`500 MG
`1 CC
`500 MG
`100 MG
`10 CC
`500 MG
`500 MG
`500 MG
`500 MG
`500 MG
`0.5 ML
`500 MG
`0.5 ML
`80 MG
`50 MG
`1 MG
`100 MCG
`5 MG
`50 MG
`1 MG
`10 UNITS
`1000 UNITS
`2500 IU
`10 MG
`0.5 MG
`250 UNITS
`
`0.637
`163.981
`79.320
`7.460
`5.189
`0.824
`8.303
`5.462
`0.513
`0.559
`1.670
`355.641
`201.117
`15.728
`28.076
`33.702
`21.017
`8.689
`149.566
`299.937
`255.101
`288.256
`457.997
`3.893
`7.173
`1.717
`359.703
`36.517
`23.977
`36.782
`7.651
`239.774
`40.468
`35.748
`31.491
`39.265
`73.710
`51.030
`36.080
`51.030
`1.448
`30.153
`127.978
`0.502
`1.323
`19.620
`16.586
`0.152
`0.182
`12.988
`1.576
`3.912
`272.515
`
`95
`
`95
`
`0.750
`
`4.740
`
`95
`
`12.640
`
`95
`
`35.250
`
`AMP-based payment limit
`
`updated July 2014
`updated July 2014
`
`updated July 2014
`
`Exhibit 2234
`Page 04 of 11
`
`

`

`J1720
`J1740
`J1742
`J1743
`J1745
`J1750
`J1756
`J1786
`J1790
`J1800
`J1815
`J1817
`J1840
`J1850
`J1885
`J1930
`J1931
`J1940
`J1945
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2185
`J2210
`J2248
`J2250
`J2260
`J2270
`J2271
`J2275
`J2278
`J2280
`J2300
`J2310
`J2315
`J2323
`J2325
`J2353
`J2354
`J2355
`J2357
`J2358
`J2360
`J2370
`J2400
`
`Hydrocortisone sodium succ i
`Ibandronate sodium injection
`Ibutilide fumarate injection
`Idursulfase injection
`Infliximab injection
`Inj iron dextran
`Iron sucrose injection
`Imuglucerase injection
`Droperidol injection
`Propranolol injection
`Insulin injection
`Insulin for insulin pump use
`Kanamycin sulfate 500 MG inj
`Kanamycin sulfate 75 MG inj
`Ketorolac tromethamine inj
`Lanreotide injection
`Laronidase injection
`Furosemide injection
`Lepirudin
`Leuprolide acetate /3.75 MG
`Levetiracetam injection
`Inj levocarnitine per 1 gm
`Levofloxacin injection
`Hyoscyamine sulfate inj
`Lidocaine injection
`Lincomycin injection
`Linezolid injection
`Lorazepam injection
`Mannitol injection
`Meperidine hydrochl /100 MG
`Meropenem
`Methylergonovin maleate inj
`Micafungin sodium injection
`Inj midazolam hydrochloride
`Inj milrinone lactate / 5 MG
`Morphine sulfate injection
`Morphine so4 injection 100mg
`Morphine sulfate injection
`Ziconotide injection
`Inj, moxifloxacin 100 mg
`Inj nalbuphine hydrochloride
`Inj naloxone hydrochloride
`Naltrexone, depot form
`Natalizumab injection
`Nesiritide injection
`Octreotide injection, depot
`Octreotide inj, non-depot
`Oprelvekin injection
`Omalizumab injection
`Olanzapine long-acting inj
`Orphenadrine injection
`Phenylephrine hcl injection
`Chloroprocaine hcl injection
`
`100 MG
`1 MG
`1 MG
`1 MG
`10 MG
`50 MG
`1 MG
`10 UNITS
`5 MG
`1 MG
`5 UNITS
`50 UNITS
`500 MG
`75 MG
`15 MG
`1 MG
`0.1 MG
`20 MG
`50 MG
`3.75 MG
`10 MG
`1 GM
`250 MG
`0.25 MG
`10 MG
`300 MG
`200 MG
`2 MG
`50 ML
`100 MG
`100 MG
`0.2 MG
`1 MG
`1 MG
`5 MG
`10 MG
`100 MG
`10 MG
`1 MCG
`100 MG
`10 MG
`1 MG
`1 MG
`1 MG
`0.1 MG
`1 MG
`25 MCG
`5 MG
`5 MG
`1 MG
`60 MG
`1 ML
`30 ML
`
`4.825
`155.248
`78.930
`469.120
`69.958
`12.130
`0.272
`42.007
`2.141
`2.041
`0.590
`5.850
`7.685
`1.153
`0.596
`37.161
`28.313
`3.606
`570.540
`747.918
`0.151
`8.734
`2.559
`17.277
`0.018
`7.766
`39.710
`0.711
`1.420
`2.373
`0.751
`3.941
`0.948
`0.129
`2.582
`5.285
`0.529
`3.776
`6.602
`3.388
`1.269
`13.656
`2.804
`12.992
`60.255
`136.138
`1.423
`276.596
`25.520
`2.753
`5.232
`4.590
`16.529
`
`95
`
`2.800
`
`95
`
`0.560
`
`95
`95
`95
`95
`
`51.580
`0.710
`11.070
`4.390
`
`AMP-based payment limit
`
`updated July 2014
`
`updated January 2014
`
`AMP-based payment limit
`updated July 2014
`
`Exhibit 2234
`Page 05 of 11
`
`

`

`J2405
`J2410
`J2425
`J2426
`J2430
`J2469
`J2501
`J2503
`J2504
`J2505
`J2507
`J2510
`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2562
`J2590
`J2597
`J2675
`J2680
`J2690
`J2700
`J2720
`J2724
`J2730
`J2760
`J2765
`J2770
`J2778
`J2780
`J2783
`J2785
`J2788
`J2790
`J2791
`J2792
`J2794
`J2795
`J2796
`J2800
`J2805
`J2810
`J2820
`J2850
`J2916
`J2920
`J2930
`J2993
`J2997
`J3000
`
`Ondansetron hcl injection
`Oxymorphone hcl injection
`Palifermin injection
`Paliperidone palmitate inj
`Pamidronate disodium /30 MG
`Palonosetron hcl
`Paricalcitol
`Pegaptanib sodium injection
`Pegademase bovine, 25 iu
`Injection, pegfilgrastim 6mg
`Pegloticase injection
`Penicillin g procaine inj
`Pentobarbital sodium inj
`Penicillin g potassium inj
`Piperacillin/tazobactam
`Pentamidine non-comp unit
`Promethazine hcl injection
`Phenobarbital sodium inj
`Plerixafor injection
`Oxytocin injection
`Inj desmopressin acetate
`Inj progesterone per 50 MG
`Fluphenazine decanoate 25 MG
`Procainamide hcl injection
`Oxacillin sodium injeciton
`Inj protamine sulfate/10 MG
`Protein c concentrate
`Pralidoxime chloride inj
`Phentolaine mesylate inj
`Metoclopramide hcl injection
`Quinupristin/dalfopristin
`Ranibizumab injection
`Ranitidine hydrochloride inj
`Rasburicase
`Regadenoson injection
`Rho d immune globulin 50 mcg
`Rho d immune globulin inj
`Rhophylac injection
`Rho(D) immune globulin h, sd
`Risperidone, long acting
`Ropivacaine HCl injection
`Romiplostim injection
`Methocarbamol injection
`Sincalide injection
`Inj theophylline per 40 MG
`Sargramostim injection
`Inj secretin synthetic human
`Na ferric gluconate complex
`Methylprednisolone injection
`Methylprednisolone injection
`Reteplase injection
`Alteplase recombinant
`Streptomycin injection
`
`1 MG
`1 MG
`50 MCG
`1 MG
`30 MG
`25 MCG
`1 MCG
`0.3 MG
`25 IU
`6 MG
`1 MG
`600000 UNITS
`50 MG
`600000 UNITS
`1.125 GM
`300 MG
`50 MG
`120 MG
`1 MG
`10 UNITS
`1 MCG
`50 MG
`25 MG
`1 GM
`250 MG
`10 MG
`10 UNITS
`1 GM
`5 MG
`10 MG
`500 MG
`0.1 mg
`25 MG
`0.5 MG
`0.1 MG
`50 MCG (250 IU)
`300 MCG (1500 IU)
`100 IU
`100 IU
`0.5 MG
`1 MG
`10 MCG
`10 ML
`5 MCG
`40 MG
`50 MCG
`1 MCG
`12.5 MG
`40 MG
`125 MG
`18.1 MG
`1 MG
`1 GM
`
`0.119
`2.351
`14.365
`7.434
`10.717
`19.384
`1.619
`1026.695
`275.883
`3123.833
`508.885
`14.927
`32.159
`0.603
`1.701
`82.924
`1.570
`14.445
`297.654
`0.431
`5.628
`1.491
`18.995
`18.861
`1.723
`0.861
`14.258
`88.934
`114.639
`0.530
`194.323
`397.258
`1.062
`211.353
`53.427
`25.145
`82.685
`4.778
`18.674
`5.777
`0.099
`51.117
`38.132
`83.109
`0.308
`28.592
`27.494
`2.904
`1.741
`2.576
`2301.907
`56.014
`10.280
`
`updated July 2014
`
`updated July 2014
`
`Updated April 2014
`
`Exhibit 2234
`Page 06 of 11
`
`

`

`95
`
`0.700
`
`J3010
`J3070
`J3095
`J3101
`J3105
`J3120
`J3130
`J3230
`J3240
`J3243
`J3246
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`J3302
`J3303
`J3315
`J3355
`J3357
`J3360
`J3370
`J3385
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`J3470
`J3473
`J3475
`J3480
`J3485
`J3486
`J7030
`J7040
`J7042
`J7050
`J7060
`J7070
`J7100
`J7120
`J7183
`J7185
`J7186
`J7187
`J7189
`J7190
`J7192
`
`Fentanyl citrate injeciton
`Pentazocine injection
`Telavancin injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Testosterone enanthate inj
`Testosterone enanthate inj
`Chlorpromazine hcl injection
`Thyrotropin injection
`Tigecycline injection
`Tirofiban HCl
`Trimethobenzamide hcl inj
`Tobramycin sulfate injection
`Tocilizumab injection
`Treprostinil injection
`Triamcinolone A inj PRS-free
`Triamcinolone acet inj NOS
`Triamcinolone diacetate inj
`Triamcinolone hexacetonl inj
`Triptorelin pamoate
`Urofollitropin, 75 iu
`Ustekinumab injection
`Diazepam injection
`Vancomycin hcl injection
`Velaglucerase alfa
`Verteporfin injection
`Hydroxyzine hcl injection
`Thiamine hcl 100 mg
`Pyridoxine hcl 100 mg
`Vitamin b12 injection
`Vitamin k phytonadione inj
`Injection, voriconazole
`Hyaluronidase injection
`Hyaluronidase recombinant
`Inj magnesium sulfate
`Inj potassium chloride
`Zidovudine
`Ziprasidone mesylate
`Normal saline solution infus
`Normal saline solution infus
`5% dextrose/normal saline
`Normal saline solution infus
`5% dextrose/water
`D5w infusion
`Dextran 40 infusion
`Ringers lactate infusion
`Wilate injection
`Xyntha inj
`Antihemophilic viii/vwf comp
`Humate-P, inj
`Factor viia
`Factor viii
`Factor viii recombinant NOS
`
`0.1 MG
`30 MG
`10 MG
`1 MG
`1 MG
`100 MG
`200 MG
`50 MG
`0.9 MG
`1 MG
`0.25 MG
`200 MG
`80 MG
`1 MG
`1 MG
`1 MG
`10 MG
`5 MG
`5 MG
`3.75 MG
`75 IU
`1 MG
`5 MG
`500 MG
`100 UNITS
`0.1 MG
`25 MG
`100 MG
`100 MG
`1000 MCG
`1 MG
`10 MG
`150 UNITS
`1 USP UNIT
`500 MG
`2 MEQ
`10 MG
`10 MG
`1000 ML
`500 ML
`500 ML
`250 ML
`500 ML
`1000 CC
`500 ML
`1000 CC
`1 I.U. VWF:RCO
`1 IU
`PER FACTOR VIII IU
`1 IU
`1 MCG
`1 IU
`1 IU
`
`0.596
`31.745
`2.646
`78.986
`1.634
`7.204
`10.198
`19.899
`1212.342
`1.770
`8.954
`10.354
`2.290
`3.703
`61.237
`3.955
`1.740
`0.280
`2.558
`199.088
`67.368
`142.166
`3.261
`1.940
`348.350
`10.445
`0.392
`3.573
`8.217
`0.810
`0.773
`4.485
`21.200
`0.310
`0.227
`0.013
`1.499
`9.544
`1.146
`0.573
`0.485
`0.286
`1.016
`2.018
`21.760
`1.001
`0.912
`1.136
`0.930
`0.904
`1.650
`0.920
`1.128
`
`updated July 2014
`
`1
`1
`1
`1
`1
`1
`1
`
`Exhibit 2234
`Page 07 of 11
`
`

`

`J7193
`J7194
`J7195
`J7197
`J7198
`J7308
`J7309
`J7310
`J7311
`J7312
`J7321
`J7323
`J7324
`J7325
`J7326
`J7330
`J7335
`J7500
`J7501
`J7502
`J7504
`J7505
`J7506
`J7507
`J7509
`J7510
`J7511
`J7513
`J7515
`J7516
`J7517
`J7518
`J7520
`J7525
`J7527
`J7605
`J7606
`J7608
`J7611
`J7612
`J7613
`J7614
`J7620
`J7626
`J7631
`J7639
`J7644
`J7665
`J7669
`J7674
`J7682
`J7686
`J8501
`
`Factor IX non-recombinant
`Factor ix complex
`Factor IX recombinant
`Antithrombin iii injection
`Anti-inhibitor
`Aminolevulinic acid hcl top
`Methyl aminolevulinate, top
`Ganciclovir long act implant
`Fluocinolone acetonide implt
`Dexamethasone intra implant
`Hyalgan/supartz inj per dose
`Euflexxa inj per dose
`Orthovisc inj per dose
`Synvisc or Synvisc-One
`Gel-One
`Cultured chondrocytes implnt
`Capsaicin 8% patch
`Azathioprine oral 50mg
`Azathioprine parenteral
`Cyclosporine oral 100 mg
`Lymphocyte immune globulin
`Monoclonal antibodies
`Prednisone oral
`Tacrolimus oral per 1 MG
`Methylprednisolone oral
`Prednisolone oral per 5 mg
`Antithymocyte globuln rabbit
`Daclizumab, parenteral
`Cyclosporine oral 25 mg
`Cyclosporin parenteral 250mg
`Mycophenolate mofetil oral
`Mycophenolic acid
`Sirolimus, oral
`Tacrolimus injection
`Oral everolimus
`Arformoterol non-comp unit
`Formoterol fumarate, inh
`Acetylcysteine non-comp unit
`Albuterol non-comp con
`Levalbuterol non-comp con
`Albuterol non-comp unit
`Levalbuterol non-comp unit
`Albuterol ipratrop non-comp
`Budesonide non-comp unit
`Cromolyn sodium noncomp unit
`Dornase alfa non-comp unit
`Ipratropium bromide non-comp
`Mannitol for inhaler
`Metaproterenol non-comp unit
`Methacholine chloride, neb
`Tobramycin non-comp unit
`Treprostinil, non-comp unit
`Oral aprepitant
`
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`354 MG
`1 GM
`4.5 MG
`0.59 MG
`0.1 MG
`per dose
`per dose
`per dose
`1 MG
`per dose
`1 EA
`10 SQ CM
`50 MG
`100 MG
`100 MG
`250 MG
`5 MG
`5 MG
`1 MG
`4 MG
`5 MG
`25 MG
`25 MG
`25 MG
`250 MG
`250 MG
`180 MG
`1 MG
`5 MG
`0.25 MG
`15 mcg
`20 MCG
`1 GM
`1 MG
`0.5 MG
`1 MG
`0.5 MG
`2.5 MG/0.5 MG
`0.5 MG
`10 MG
`1 MG
`1 MG
`5 MG
`10 MG
`1 MG
`300 MG
` 1.74 MG
`5 MG
`
`0.949
`1.098
`1.383
`3.106
`1.638
`172.600
`83.687
`16960.000
`19345.000
`195.912
`88.852
`153.414
`177.157
`12.830
`613.284
`30549.348
`25.554
`0.124
`83.125
`3.180
`721.063
`1156.078
`0.038
`1.716
`0.535
`0.035
`569.528
`526.343
`0.885
`31.542
`1.032
`3.812
`13.280
`136.893
`6.475
`5.550
`6.300
`1.961
`0.103
`0.229
`0.049
`0.123
`0.180
`5.952
`0.495
`32.778
`0.240
`0.669
`0.435
`0.494
`119.999
`460.450
`6.688
`
`1
`1
`1
`
`1
`
`updated July 2014
`
`updated July 2014
`
`updated January 2014
`updated July 2014
`
`Exhibit 2234
`Page 08 of 11
`
`

`

`J8510
`J8520
`J8521
`J8530
`J8540
`J8560
`J8562
`J8600
`J8610
`J8700
`J8705
`J9000
`J9010
`J9017
`J9019
`J9020
`J9025
`J9027
`J9031
`J9033
`J9035
`J9040
`J9041
`J9042
`J9043
`J9045
`J9050
`J9055
`J9060
`J9065
`J9070
`J9098
`J9100
`J9120
`J9130
`J9150
`J9155
`J9160
`J9171
`J9175
`J9178
`J9179
`J9181
`J9185
`J9190
`J9200
`J9201
`J9202
`J9206
`J9207
`J9208
`J9209
`J9211
`
`Oral busulfan
`Capecitabine, oral, 150 mg
`Capecitabine, oral, 500 mg
`Cyclophosphamide oral 25 MG
`Oral dexamethasone
`Etoposide oral 50 MG
`Oral fludarabine phosphate
`Melphalan oral 2 MG
`Methotrexate oral 2.5 MG
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Alemtuzumab injection
`Arsenic trioxide injection
`Erwinaze injection
`Asparaginase, NOS
`Azacitidine injection
`Clofarabine injection
`Bcg live intravesical vac
`Bendamustine injection
`Bevacizumab injection
`Bleomycin sulfate injection
`Bortezomib injection
`Brentuximab vedotin inj
`Cabazitaxel injection
`Carboplatin injection
`Carmustine injection
`Cetuximab injection
`Cisplatin 10 MG injection
`Inj cladribine per 1 MG
`Cyclophosphamide 100 MG inj
`Cytarabine liposome inj
`Cytarabine hcl 100 MG inj
`Dactinomycin injection
`Dacarbazine 100 mg inj
`Daunorubicin injection
`Degarelix injection
`Denileukin diftitox inj
`Docetaxel injection
`Elliotts b solution per ml
`Inj, epirubicin hcl, 2 mg
`Eribulin mesylate injection
`Etoposide injection
`Fludarabine phosphate inj
`Fluorouracil injection
`Floxuridine injection
`Gemcitabine hcl injection
`Goserelin acetate implant
`Irinotecan injection
`Ixabepilone injection
`Ifosfamide injection
`Mesna injection
`Idarubicin hcl injection
`
`2 MG
`150 MG
`500 MG
`25 MG
`0.25 MG
`50 MG
`10 MG
`2 MG
`2.5 MG
`5 MG
`0.25 mg
`10 MG
`10 MG
`1 MG
`1,000 IU
`10000 UNITS
`1 MG
`1 MG
`1 EA
`1 MG
`10 MG
`15 UNITS
`0.1 MG
`1 MG
`1 MG
`50 MG
`100 MG
`10 MG
`10 MG
`1 MG
`100 MG
`10 MG
`100 MG
`0.5 MG
`100 MG
`10 MG
`1 MG
`300 MCG
`1 MG
`1 ML
`2 MG
`0.1 MG
`10 MG
`50 MG
`500 MG
`500 MG
`200 MG
`3.6 MG
`20 MG
`1 MG
`1 GM
`200 MG
`5 MG
`
`11.029
`9.687
`32.191
`0.975
`0.178
`55.677
`81.772
`8.734
`1.082
`11.558
`89.128
`3.473
`623.633
`49.400
`344.378
`64.565
`5.744
`129.525
`120.914
`21.060
`64.622
`21.044
`44.894
`102.650
`139.109
`3.042
`870.927
`52.555
`2.111
`23.994
`39.669
`544.541
`0.965
`645.749
`3.985
`30.020
`3.717
`1646.180
`4.909
`4.074
`1.180
`98.432
`0.714
`84.169
`1.995
`67.077
`7.961
`194.192
`5.197
`68.645
`31.041
`2.855
`35.311
`
`95
`
`289.370
`
`95
`
`95
`
`61.720
`
`8.190
`
`95
`95
`
`2.070
`136.800
`
`95
`
`150.380
`
`updated July 2014
`
`updated July 2014
`
`Exhibit 2234
`Page 09 of 11
`
`

`

`J9214
`J9217
`J9218
`J9225
`J9226
`J9228
`J9230
`J9245
`J9250
`J9260
`J9261
`J9263
`J9264
`J9265
`J9266
`J9268
`J9280
`J9293
`J9300
`J9302
`J9303
`J9305
`J9307
`J9310
`J9315
`J9320
`J9328
`J9330
`J9340
`J9351
`J9355
`J9357
`J9360
`J9370
`J9390
`J9395
`P9041
`P9043
`P9045
`P9046
`P9047
`P9048
`Q0138
`Q0139
`Q0162
`Q0163
`Q0164
`Q0165
`Q0166
`Q0167
`Q0168
`Q0169
`Q0170
`
`Interferon alfa-2b inj
`Leuprolide acetate suspnsion
`Leuprolide acetate injeciton
`Vantas implant
`Supprelin LA implant
`Ipilimumab injection
`Mechlorethamine hcl inj
`Inj melphalan hydrochl 50 MG
`Methotrexate sodium inj
`Methotrexate sodium inj
`Nelarabine injection
`Oxaliplatin
`Paclitaxel protein bound
`Paclitaxel injection
`Pegaspargase injection
`Pentostatin injection
`Mitomycin injection
`Mitoxantrone hydrochl / 5 MG
`Gemtuzumab ozogamicin inj
`Ofatumumab injection
`Panitumumab injection
`Pemetrexed injection
`Pralatrexate injection
`Rituximab injection
`Romidepsin injection
`Streptozocin injection
`Temozolomide injection
`Temsirolimus injection
`Thiotepa injection
`Topotecan injection
`Trastuzumab injection
`Valrubicin injection
`Vinblastine sulfate inj
`Vincristine sulfate 1 MG inj
`Vinorelbine tartrate inj
`Injection, Fulvestrant
`Albumin (human),5%, 50ml
`Plasma protein fract,5%,50ml
`Albumin (human), 5%, 250 ml
`Albumin (human), 25%, 20 ml
`Albumin (human), 25%, 50ml
`Plasmaprotein fract,5%,250ml
`Ferumoxytol, non-esrd
`Ferumoxytol, esrd use
`Ondansetron oral
`Diphenhydramine HCl 50mg
`Prochlorperazine maleate 5mg
`Prochlorperazine maleate10mg
`Granisetron hcl 1 mg oral
`Dronabinol 2.5mg oral
`Dronabinol 5mg oral
`Promethazine HCl 12.5mg oral
`Promethazine HCl 25 mg oral
`
`1 MIL UNITS
`7.5 MG
`1 MG
`50 MG
`50 MG
`1 MG
`10 MG
`50 MG
`5 MG
`50 MG
`50 MG
`0.5 MG
`1 MG
`30 MG
`1 EA
`10 MG
`5 MG
`5 MG
`5 MG
`10 MG
`10 MG
`10 MG
`1 MG
`100 MG
`1 MG
`1 GM
`1 MG
`1 MG
`15 MG
`0.1 MG
`10 MG
`200 MG
`1 MG
`1 MG
`10 MG
`25 MG
`50 ML
`50 ML
`250 ML
`20 ML
`50 ML
`250 ML
`1 MG
`1 MG
`1 MG
`50 MG
`5 MG
`10 MG
`1 MG
`2.5 MG
`5 MG
`12.5 MG
`25 MG
`
`20.695
`202.837
`10.250
`2966.802
`16660.709
`128.955
`154.698
`1293.550
`0.255
`2.498
`130.634
`0.535
`9.553
`4.348
`6007.380
`1419.700
`24.535
`34.619
`2742.591
`46.530
`91.380
`59.488
`182.611
`678.702
`251.936
`274.345
`5.027
`55.970
`630.700
`2.196
`78.720
`1052.978
`1.658
`5.767
`8.810
`89.677
`9.546
`8.816
`47.728
`19.680
`49.201
`44.080
`0.681
`0.681
`0.042
`0.029
`0.026
`0.036
`2.539
`3.346
`6.822
`0.062
`0.085
`
`95
`
`95
`95
`
`58.130
`
`4.100
`33.980
`
`95
`95
`95
`95
`95
`95
`
`9.546
`8.816
`47.728
`19.680
`49.201
`44.080
`
`updated July 2014
`
`updated July 2014
`
`Exhibit 2234
`Page 10 of 11
`
`

`

`95
`95
`95
`95
`
`11.543
`8.579
`14.963
`12.044
`
`Q0180
`Q2009
`Q2017
`Q2035
`Q2036
`Q2037
`Q2038
`Q2043
`Q2049
`Q2050
`Q2051
`Q3025
`Q4074
`Q4081
`Q4101
`Q4102
`Q4103
`Q4104
`Q4105
`Q4106
`Q4107
`Q4108
`Q4110
`Q4111
`Q4112
`Q4113
`Q4114
`Q4115
`Q4116
`Q4121
`Q4123
`Q9956
`Q9957
`Q9958
`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`
`Dolasetron mesylate oral
`Fosphenytoin inj PE
`Teniposide, 50 mg
`Afluria vacc, 3 yrs & >, im
`Flulaval vacc, 3 yrs & >, im
`Fluvirin vacc, 3 yrs & >, im
`Fluzone vacc, 3 yrs & >, im
`Sipuleucel-T auto CD54+
`Imported Lipodox inj
`Doxorubicin inj 10mg
`Zoledronic acid 1mg
`IM inj interferon beta 1-a
`Iloprost non-comp unit dose
`Epoetin alfa, 100 units ESRD
`Apligraf skin sub
`Oasis wound matrix skin sub
`Oasis burn matrix skin sub
`Integra BMWD skin sub
`Integra DRT skin sub
`Dermagraft skin sub
`Graftjacket skin sub
`Integra matrix skin sub
`Primatrix skin sub
`Gammagraft skin sub
`Cymetra allograft
`Graftjacket express allograf
`Integra flowable wound matri
`Alloskin
`Alloderm skin sub
`Theraskin
`Alloskin RT
`Inj octafluoropropane mic,ml
`Inj perflutren lip micros,ml
`HOCM <=149 mg/ml iodine, 1ml
`HOCM 200-249mg/ml iodine,1ml
`HOCM 250-299mg/ml iodine,1ml
`HOCM 350-399mg/ml iodine,1ml
`LOCM 100-199mg/ml iodine,1ml
`LOCM 200-299mg/ml iodine,1ml
`LOCM 300-399mg/ml iodine,1ml
`
`
`
`100 MG
`50 MG
`50 MG
`0.5 ml
`0.5 ML
`0.5 ML
`0.5 ML
`fusion (minimum 50 million
`10 MG
`10 MG
`1 MG
`11 MCG
`UP TO 20 MCG
`100 UNITS
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 CC
`1 CC
`1 CC
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`
`69.470
`1.169
`332.617
`11.543
`8.579
`14.963
`12.044
`32709.976
`498.264
`545.476
`150.326
`307.141
`77.380
`1.122
`41.061
`9.507
`9.507
`25.747
`13.135
`44.433
`98.503
`28.457
`38.594
`6.913
`392.700
`392.700
`1235.313
`12.681
`32.891
`23.205
`15.450
`36.651
`54.976
`0.090
`0.168
`0.184
`0.175
`0.974
`0.254
`0.163
`
`Exhibit 2234
`Page 11 of 11
`
`