Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q16 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, 2016 through December 31, 2016
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`50 MG
`1 EACH
`
`Payment Limit
`111.332
`305.475
`294.585
`123.195
`123.195
`
`0.1 ml
`1 ML
`
`0.5 ml
`
`Short Description
`Hep b ig im
`Rabies ig im/sc
`Rabies ig heat treated
`Bcg vaccine percut
`Bcg vaccine, intravesical
`
`Flu vacc iiv4 no preserv id
`Hep a vaccine, adult im
`
`Iiv adjuvant vaccine im
`
`HCPCS Code
`90371
`90375
`90376
`90585
`90586
`
`90630
`90632
`
`90653
`
`90656
`
`90662
`90670
`
`90672
`
`90673
`
`90674
`90675
`
`90685
`
`90686
`
`90687
`
`90688
`90691
`90714
`90715
`90732
`90740
`90743
`90744
`90746
`
`IIV3 VACC NO PRSV 0.5 ML IM
`
`0.50 ML
`
`Iiv no prsv increased ag im
`Pneumococcal vacc, 13 val im
`
`Laiv4 vaccine intranasal
`
`Riv3 vaccine no preserv im
`
`CCIIV4 VAC NO PRSV 0.5 ML IM
`Rabies vaccine im
`
`IIV4 VACC NO PRSV 0.25 ML IM
`
`IIV4 VACC NO PRSV 0.5 ML IM
`
`IIV4 VACCINE SPLT 0.25 ML IM
`
`IIV4 VACCINE SPLT 0.5 ML IM
`Typhoid vaccine, im
`Td vaccine no prsrv >/= 7 yo, im
`Tdap => 7 yo, im
`Pneumococcal vaccine
`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
`
`0.5 ML
`0.5 ML
`
`0.2 ml
`
`0.5 ML
`
`0.5 ML
`1 ML
`
`0.25 mL
`
`0.5 ml
`
`0.25 ML
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`40 MCG
`1 DOSE
`1 DOSE
`20 MCG
`
`Vaccine
`AWP%
`
`Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`20.343
`50.854
`
`37.383
`
`17.717
`
`42.722
`181.061
`
`26.876
`
`40.613
`
`22.936
`272.489
`
`26.268
`
`19.032
`
`9.403
`
`17.835
`84.037
`24.188
`31.367
`89.945
`122.957
`25.392
`25.392
`61.475
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`
`20.343
`
`37.383
`
`17.717
`
`42.722
`181.061
`
`26.876
`
`40.613
`
`22.936
`
`26.268
`
`19.032
`
`9.403
`
`17.835
`
`89.945
`122.957
`25.392
`25.392
`61.475
`
`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
`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
`
`Exhibit 2236
`Page 01 of 11
`
`

`

`95
`
`122.957
`
`microCurie 100% AWP = $148.660
`microCurie 100% WAC = $123.880
`
`95
`95
`95
`
`10.280
`21.850
`35.800
`
`95
`95
`
`215.180
`79.800
`
`90747
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9583
`A9585
`
`A9606
`J0129
`J0130
`J0132
`J0133
`J0135
`J0153
`J0171
`J0178
`J0180
`J0202
`J0207
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0558
`J0561
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0597
`
`Hepb vacc, ill pat 4 dose im
`Inj gadoterate meglumi 0.1 ml
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base MR contrast NOS,1ml
`Gadoxetate disodium inj
`Gadofosveset trisodium inj
`Gadobutrol injection
`
`Radium ra223 dichloride ther
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Adenosine inj 1mg
`Adrenalin epinephrine inject
`Aflibercept injection
`Agalsidase beta injection
`Injection, Alemtuzumab
`Amifostine
`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
`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
`
`40 MCG
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`
`1 microCurie
`10 MG
`10 MG
`100 MG
`5 MG
`20 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`1 MG
`500 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
`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
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`10 UNITS
`
`122.957
`0.200
`1.611
`2.080
`2.013
`1.843
`13.949
`17.925
`0.388
`
`N/A
`44.750
`1136.511
`1.506
`0.074
`861.447
`0.630
`0.136
`980.455
`164.415
`1738.364
`416.532
`159.385
`4.828
`4.367
`1.479
`8.834
`27.935
`13.407
`19.012
`1.307
`3.697
`0.507
`4.591
`4.383
`3.307
`0.036
`39.337
`173.425
`76.957
`3196.111
`3.841
`42.018
`63.589
`34.420
`7.964
`10.307
`1.529
`5.930
`7.902
`11.708
`4.907
`3.372
`38.372
`2.423
`46.515
`
`Exhibit 2236
`Page 02 of 11
`
`

`

`J0598
`J0600
`J0610
`J0630
`J0636
`J0637
`J0638
`J0640
`J0641
`J0670
`J0690
`J0692
`J0694
`J0696
`J0697
`J0698
`J0702
`J0712
`J0713
`J0717
`J0720
`J0725
`J0735
`J0740
`J0743
`J0744
`J0770
`J0775
`J0780
`J0795
`J0800
`J0834
`J0840
`J0850
`J0875
`J0878
`J0881
`J0882
`J0885
`J0887
`J0888
`J0894
`J0895
`J0897
`J1000
`J1020
`J1030
`J1040
`J1050
`J1071
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`
`C-1 esterase, cinryze
`Edetate calcium disodium inj
`Calcium gluconate injection
`Calcitonin salmon injection
`Inj calcitriol per 0.1 mcg
`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
`Ceftaroline fosamil inj
`Inj ceftazidime per 500 mg
`Certolizumab Pegol Inj 1mg
`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
`Injection, dalbavancin
`Daptomycin injection
`Darbepoetin alfa, non-esrd
`Darbepoetin alfa, esrd use
`Epoetin alfa, non-esrd
`Epoetin beta esrd use
`Epoetin beta non 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
`Inj testosterone cypionate
`Dexamethasone sodium phos
`Inj dihydroergotamine mesylt
`Acetazolamid sodium injectio
`Digoxin injection
`Digoxin immune fab (ovine)
`Phenytoin sodium injection
`
`10 UNITS
`1000 MG
`10 ML
`400 UNITS
`0.1 MCG
`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
`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
`5 MG
`1 MG
`1 MCG
`1 MCG
`1000 UNITS
`1 MCG
`1 MCG
`1 MG
`500 MG
`1 MG
`5 MG
`20 MG
`40 MG
`80 MG
`1 MG
`1 MG
`1 MG
`1 MG
`500 MG
`0.5 MG
`PER VIAL
`50 MG
`
`55.546
`5594.422
`3.508
`2321.135
`0.493
`12.214
`92.494
`3.092
`0.898
`2.318
`0.948
`2.456
`4.624
`0.496
`2.873
`0.460
`6.030
`2.480
`2.255
`7.111
`40.361
`24.619
`14.305
`554.484
`7.079
`1.152
`11.185
`41.415
`11.932
`8.120
`3555.346
`43.702
`2670.235
`1126.546
`15.216
`0.904
`3.933
`3.933
`12.591
`1.479
`1.479
`20.832
`8.849
`16.227
`16.798
`4.821
`5.222
`9.800
`0.417
`0.023
`0.117
`75.490
`21.184
`4.817
`3039.529
`1.414
`
`updated October 2017
`
`95
`
`15.630
`
`Exhibit 2236
`Page 03 of 11
`
`

`

`95
`
`1.490
`
`95
`
`95
`
`0.750
`
`4.740
`
`95
`
`12.640
`
`95
`
`35.250
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`J1170
`J1190
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1260
`J1265
`J1267
`J1270
`J1290
`J1300
`J1325
`J1335
`J1364
`J1380
`J1410
`J1430
`J1439
`J1442
`J1447
`J1450
`J1453
`J1458
`J1459
`J1460
`J1556
`J1557
`J1559
`J1560
`J1561
`J1566
`J1568
`J1569
`J1570
`J1571
`J1572
`J1575
`J1580
`J1602
`J1610
`J1626
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`J1720
`J1740
`
`Hydromorphone injection
`Dexrazoxane HCl injection
`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
`Ertapenem injection
`Erythro lactobionate /500 MG
`Estradiol valerate 10 MG inj
`Inj estrogen conjugate 25 MG
`Ethanolamine oleate 100 mg
`Inj ferric carboxymaltos 1mg
`Inj filgrastim excl biosimil
`Inj tbo filgrastim 1 microg
`Fluconazole
`Fosaprepitant injection
`Galsulfase injection
`Inj IVIG privigen 500 mg
`Gamma globulin 1 CC inj
`Inj, Imm Glob Bivigam, 500mg
`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
`Hyqvia 100mg immuneglobulin
`Garamycin gentamicin inj
`Golimumab for iv use 1mg
`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
`Hydrocortisone sodium succ i
`Ibandronate sodium injection
`
`4 MG
`250 MG
`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
`500 MG
`500 MG
`10 MG
`25 MG
`100 MG
`1 MG
`1 MCG
`1 MCG
`200 MG
`1 MG
`1 MG
`500 MG
`1 CC
`500 MG
`500 MG
`100 MG
`10 CC
`500 MG
`500 MG
`500 MG
`500 MG
`500 MG
`0.5 ML
`500 MG
`100 MG
`80 MG
`1 MG
`1 MG
`100 MCG
`5 MG
`50 MG
`1 MG
`10 UNITS
`1000 UNITS
`2500 IU
`10 MG
`0.5 MG
`250 UNITS
`100 MG
`1 MG
`
`2.143
`184.046
`0.627
`86.677
`481.940
`17.142
`6.322
`0.784
`5.272
`6.168
`0.649
`0.775
`0.918
`399.562
`221.116
`15.483
`45.170
`59.290
`9.076
`261.395
`404.093
`1.051
`1.003
`0.742
`4.336
`1.886
`364.405
`37.898
`36.412
`39.521
`37.032
`9.829
`364.120
`38.582
`33.073
`35.980
`39.995
`58.653
`56.058
`36.804
`12.744
`1.405
`24.787
`199.118
`0.295
`1.520
`18.040
`22.858
`0.180
`0.212
`15.921
`0.873
`2.239
`433.063
`8.531
`101.963
`
`Exhibit 2236
`Page 04 of 11
`
`

`

`95
`
`2.800
`
`95
`
`0.560
`
`95
`
`0.710
`
`J1742
`J1743
`J1745
`J1750
`J1756
`J1786
`J1800
`J1815
`J1817
`J1885
`J1930
`J1931
`J1940
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2185
`J2210
`J2248
`J2250
`J2270
`J2274
`J2278
`J2280
`J2300
`J2310
`J2315
`J2323
`J2353
`J2354
`J2355
`J2357
`J2358
`J2360
`J2400
`J2405
`J2407
`J2410
`J2425
`J2426
`J2430
`J2469
`J2501
`J2503
`J2504
`J2505
`J2507
`J2510
`
`Ibutilide fumarate injection
`Idursulfase injection
`Infliximab injection
`Inj iron dextran
`Iron sucrose injection
`Imuglucerase injection
`Propranolol injection
`Insulin injection
`Insulin for insulin pump use
`Ketorolac tromethamine inj
`Lanreotide injection
`Laronidase injection
`Furosemide injection
`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
`Morphine sulfate injection
`In morphine preservativ free
`Ziconotide injection
`Inj, moxifloxacin 100 mg
`Inj nalbuphine hydrochloride
`Inj naloxone hydrochloride
`Naltrexone, depot form
`Natalizumab injection
`Octreotide injection, depot
`Octreotide inj, non-depot
`Oprelvekin injection
`Omalizumab injection
`Olanzapine long-acting inj
`Orphenadrine injection
`Chloroprocaine hcl injection
`Ondansetron hcl injection
`Injection, oritavancin
`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
`
`1 MG
`1 MG
`10 MG
`50 MG
`1 MG
`10 UNITS
`1 MG
`5 UNITS
`50 UNITS
`15 MG
`1 MG
`0.1 MG
`20 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
`10 MG
`10MG
`1 MCG
`100 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`25 MCG
`5 MG
`5 MG
`1 MG
`60 MG
`30 ML
`1 MG
`10 MG
`1 MG
`50 MCG
`1 MG
`30 MG
`25 MCG
`1 MCG
`0.3 MG
`25 IU
`6 MG
`1 MG
`600000 UNITS
`
`186.194
`522.035
`82.872
`12.405
`0.255
`41.932
`1.145
`0.801
`9.098
`0.666
`51.308
`30.587
`2.051
`1038.696
`0.142
`19.888
`1.663
`27.854
`0.018
`12.058
`15.779
`0.803
`1.849
`5.094
`1.308
`8.034
`0.965
`0.140
`1.230
`9.052
`7.306
`8.487
`2.518
`32.405
`3.239
`17.894
`168.110
`1.190
`467.216
`32.306
`2.917
`3.671
`25.951
`0.130
`24.642
`2.888
`17.679
`9.117
`10.419
`22.882
`3.170
`1054.700
`319.673
`4040.693
`1642.455
`26.766
`
`Exhibit 2236
`Page 05 of 11
`
`

`

`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2562
`J2597
`J2675
`J2680
`J2690
`J2700
`J2704
`J2720
`J2724
`J2765
`J2770
`J2778
`J2780
`J2783
`J2785
`J2788
`J2790
`J2791
`J2792
`J2794
`J2795
`J2796
`J2800
`J2805
`J2810
`J2820
`J2850
`J2916
`J2920
`J2930
`J2997
`J3000
`J3010
`J3060
`J3070
`J3090
`J3095
`J3101
`J3105
`J3121
`J3230
`J3240
`J3243
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`J3303
`
`Pentobarbital sodium inj
`Penicillin g potassium inj
`Piperacillin/tazobactam
`Pentamidine non-comp unit
`Promethazine hcl injection
`Phenobarbital sodium inj
`Plerixafor injection
`Inj desmopressin acetate
`Inj progesterone per 50 MG
`Fluphenazine decanoate 25 MG
`Procainamide hcl injection
`Oxacillin sodium injeciton
`Inj, propofol, 10 mg
`Inj protamine sulfate/10 MG
`Protein c concentrate
`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
`Alteplase recombinant
`Streptomycin injection
`Fentanyl citrate injeciton
`Inj, Taliglucerace Alfa 10 u
`Pentazocine injection
`Inj tedizolid phosphate
`Telavancin injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Inj testostero enanthate 1mg
`Chlorpromazine hcl injection
`Thyrotropin injection
`Tigecycline injection
`Trimethobenzamide hcl inj
`Tobramycin sulfate injection
`Tocilizumab injection
`Treprostinil injection
`Triamcinolone A inj PRS-free
`Triamcinolone acet inj NOS
`Triamcinolone hexacetonl inj
`
`50 MG
`600000 UNITS
`1.125 GM
`300 MG
`50 MG
`120 MG
`1 MG
`1 MCG
`50 MG
`25 MG
`1 GM
`250 MG
`10 MG
`10 MG
`10 UNITS
`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
`1 MG
`1 GM
`0.1 MG
`10 UNITS
`30 MG
`1 MG
`10 MG
`1 MG
`1 MG
`1 MG
`50 MG
`0.9 MG
`1 MG
`200 MG
`80 MG
`1 MG
`1 MG
`1 MG
`10 MG
`5 MG
`
`47.175
`1.029
`2.898
`118.847
`1.637
`29.803
`312.108
`14.043
`1.373
`22.783
`55.602
`1.613
`0.123
`1.118
`15.229
`0.894
`413.521
`383.227
`1.094
`254.107
`53.896
`27.014
`81.446
`4.743
`21.329
`7.819
`0.074
`62.137
`38.570
`97.445
`0.299
`36.228
`34.781
`2.295
`3.726
`5.126
`80.290
`13.342
`0.498
`40.462
`140.385
`1.277
`5.017
`102.431
`3.126
`0.040
`23.119
`1571.304
`3.129
`25.919
`1.390
`4.103
`61.237
`3.703
`1.769
`3.612
`
`95
`
`0.700
`
`Exhibit 2236
`Page 06 of 11
`
`

`

`J3315
`J3357
`J3360
`J3370
`J3380
`J3385
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`J3471
`J3473
`J3475
`J3480
`J3485
`J3486
`J3489
`J7030
`J7040
`J7042
`J7050
`J7060
`J7070
`J7120
`J7180
`J7182
`J7183
`J7185
`J7186
`J7187
`J7189
`J7190
`J7192
`J7193
`J7194
`J7195
`J7197
`J7198
`J7200
`J7201
`J7205
`J7308
`J7311
`J7312
`J7313
`J7316
`J7321
`J7323
`J7324
`J7325
`J7326
`J7327
`J7336
`
`Triptorelin pamoate
`Ustekinumab injection
`Diazepam injection
`Vancomycin hcl injection
`Injection, vedolizumab
`Velaglucerase alfa
`Verteporfin injection
`Hydroxyzine hcl injection
`Thiamine hcl 100 mg
`Pyridoxine hcl 100 mg
`Vitamin b12 injection
`Vitamin k phytonadione inj
`Injection, voriconazole
`Ovine, up to 999 usp units
`Hyaluronidase recombinant
`Inj magnesium sulfate
`Inj potassium chloride
`Zidovudine
`Ziprasidone mesylate
`Zoledronic Acid 1mg
`Normal saline solution infus
`Normal saline solution infus
`5% dextrose/normal saline
`Normal saline solution infus
`5% dextrose/water
`D5w infusion
`Ringers lactate infusion
`Factor xiii anti-hem factor
`Factor viii recomb novoeight
`Wilate injection
`Xyntha inj
`Antihemophilic viii/vwf comp
`Humate-P, inj
`Factor viia
`Factor viii
`Factor viii recombinant NOS
`Factor IX non-recombinant
`Factor ix complex
`Factor IX recombinant NOS
`Antithrombin iii injection
`Anti-inhibitor
`Factor ix recombinan rixubis
`Factor ix fc fusion recomb
`Factor viii fc fusion recomb
`Aminolevulinic acid hcl top
`Fluocinolone acetonide implt
`Dexamethasone intra implant
`Fluocinol acet intravit imp
`Inj, Ocriplasmin, 0.125 mg
`Hyalgan/supartz inj per dose
`Euflexxa inj per dose
`Orthovisc inj per dose
`Synvisc or Synvisc-One
`Gel-One
`Monovisc inj per dose
`Capsaicin 8% patch
`
`3.75 MG
`1 MG
`5 MG
`500 MG
`1 MG
`100 UNITS
`0.1 MG
`25 MG
`100 MG
`100 MG
`1000 MCG
`1 MG
`10 MG
`1 UNIT
`1 USP UNIT
`500 MG
`2 MEQ
`10 MG
`10 MG
`1 MG
`1000 ML
`500 ML
`500 ML
`250 ML
`500 ML
`1000 CC
`1000 CC
`1 IU
`1 IU
`1 I.U. VWF:RCO
`1 IU
`PER FACTOR VIII IU
`1 IU
`1 MCG
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`354 MG
`0.59 MG
`0.1 MG
`0.01 MG
`0.125 MG
`per dose
`per dose
`per dose
`1 MG
`per dose
`Per Dose
`1 SQ CM
`
`460.851
`174.572
`9.259
`2.979
`17.431
`343.345
`10.883
`2.394
`3.244
`9.522
`4.635
`3.492
`4.638
`0.354
`0.358
`0.258
`0.129
`1.506
`18.876
`15.667
`1.880
`0.941
`0.793
`0.469
`1.853
`3.619
`2.149
`8.180
`1.310
`0.973
`1.204
`0.969
`1.035
`1.903
`0.979
`1.197
`1.105
`1.287
`1.517
`3.434
`1.921
`1.248
`2.815
`1.892
`327.413
`20126.595
`200.903
`490.947
`1046.750
`87.730
`155.315
`159.279
`12.769
`587.579
`917.768
`2.979
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`1
`1
`1
`1
`
`Exhibit 2236
`Page 07 of 11
`
`

`

`AMP-based payment limit
`
`J7500
`J7502
`J7503
`J7504
`J7507
`J7508
`J7509
`J7510
`J7511
`J7512
`J7515
`J7516
`J7517
`J7518
`J7520
`J7525
`J7527
`J7605
`J7606
`J7608
`J7611
`J7612
`J7613
`J7614
`J7620
`J7626
`J7631
`J7639
`J7644
`J7674
`J7682
`J7686
`J8501
`J8510
`J8520
`J8521
`J8530
`J8540
`J8560
`J8600
`J8610
`J8655
`J8700
`J8705
`J9000
`J9017
`J9019
`J9025
`J9027
`J9031
`J9032
`J9033
`J9035
`J9040
`J9041
`J9042
`
`Azathioprine oral 50mg
`Cyclosporine oral 100 mg
`Tacrol envarsus ex rel oral
`Lymphocyte immune globulin
`Tacrolimus Imme Rel oral 1mg
`Tacrol astagraf ex rel oral
`Methylprednisolone oral
`Prednisolone oral per 5 mg
`Antithymocyte globuln rabbit
`Prednisone ir or dr oral 1mg
`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
`Methacholine chloride, neb
`Tobramycin non-comp unit
`Treprostinil, non-comp unit
`Oral aprepitant
`Oral busulfan
`Capecitabine, oral, 150 mg
`Capecitabine, oral, 500 mg
`Cyclophosphamide oral 25 MG
`Oral dexamethasone
`Etoposide oral 50 MG
`Melphalan oral 2 MG
`Methotrexate oral 2.5 MG
`Netupitant palonosetron oral
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Arsenic trioxide injection
`Erwinaze injection
`Azacitidine injection
`Clofarabine injection
`Bcg live intravesical vac
`Injection, belinostat, 10mg
`Bendamustine injection
`Bevacizumab injection
`Bleomycin sulfate injection
`Bortezomib injection
`Brentuximab vedotin inj
`
`50 MG
`100 MG
`0.25 MG
`250 MG
`1 MG
`0.1 MG
`4 MG
`5 MG
`25 MG
`1 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
`1 MG
`300 MG
` 1.74 MG
`5 MG
`2 MG
`150 MG
`500 MG
`25 MG
`0.25 MG
`50 MG
`2 MG
`2.5 MG
`0.5 MG
`5 MG
`0.25 mg
`10 MG
`1 MG
`1,000 IU
`1 MG
`1 MG
`1 EA
`10 MG
`1 MG
`10 MG
`15 UNITS
`0.1 MG
`1 MG
`
`0.333
`3.365
`1.232
`1438.737
`0.754
`0.393
`0.341
`0.101
`690.838
`0.007
`0.895
`41.560
`0.949
`2.878
`7.572
`163.772
`7.693
`8.974
`10.666
`4.826
`0.118
`0.204
`0.048
`0.073
`0.172
`3.981
`0.880
`42.501
`0.229
`0.518
`45.424
`521.876
`11.108
`23.693
`4.122
`13.777
`3.344
`0.026
`71.609
`11.708
`1.006
`461.966
`2.664
`103.853
`2.534
`64.619
`402.743
`2.844
`152.442
`123.195
`33.538
`27.014
`72.310
`28.196
`46.523
`129.089
`
`95
`
`289.370
`
`Exhibit 2236
`Page 08 of 11
`
`

`

`95
`
`95
`
`61.720
`
`8.190
`
`95
`95
`
`2.070
`136.800
`
`95
`
`150.380
`
`AMP-based payment limit
`
`AMP-based payment limit
`AMP-based payment limit
`
`J9043
`J9045
`J9047
`J9050
`J9055
`J9060
`J9065
`J9070
`J9098
`J9100
`J9120
`J9130
`J9150
`J9155
`J9171
`J9178
`J9179
`J9181
`J9185
`J9190
`J9200
`J9201
`J9202
`J9206
`J9207
`J9208
`J9209
`J9211
`J9214
`J9217
`J9218
`J9225
`J9226
`J9228
`J9230
`J9245
`J9250
`J9260
`J9261
`J9263
`J9264
`J9266
`J9267
`J9268
`J9271
`J9280
`J9293
`J9299
`J9301
`J9302
`J9303
`J9305
`J9306
`J9307
`J9308
`J9310
`
`Cabazitaxel injection
`Carboplatin injection
`Injection, Carfilzomib, 1 mg
`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
`Docetaxel injection
`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
`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
`Pegaspargase injection
`Paclitaxel injection
`Pentostatin injection
`Inj pembrolizumab
`Mitomycin injection
`Mitoxantrone hydrochl / 5 MG
`Injection, nivolumab
`Obinutuzumab inj
`Ofatumumab injection
`Panitumumab injection
`Pemetrexed injection
`Injection, Pertuzumab, 1 mg
`Pralatrexate injection
`Injection, ramucirumab
`Rituximab injection
`
`1 MG
`50 MG
`1 MG
`100 MG
`10 MG
`10 MG
`1 MG
`100 MG
`10 MG
`100 MG
`0.5 MG
`100 MG
`10 MG
`1 MG
`1 MG
`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
`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
`1 EA
`1 MG
`10 MG
`1 MG
`5 MG
`5 MG
`1 MG
`10 MG
`10 MG
`10 MG
`10 MG
`1 MG
`1 MG
`5 MG
`100 MG
`
`154.569
`3.551
`31.948
`3847.562
`55.631
`2.069
`21.747
`43.971
`595.763
`0.904
`1276.378
`3.958
`40.026
`3.623
`2.717
`1.167
`106.076
`0.687
`59.773
`1.699
`52.795
`6.307
`327.120
`4.011
`77.872
`28.182
`2.385
`29.757
`26.856
`225.012
`17.900
`3138.039
`26205.503
`142.653
`265.888
`1871.626
`0.238
`2.375
`152.209
`0.390
`10.322
`13911.229
`0.175
`1887.770
`46.495
`103.169
`36.746
`26.064
`56.203
`51.868
`105.599
`62.779
`10.645
`229.719
`55.934
`792.920
`
`Exhibit 2236
`Page 09 of 11
`
`

`

`J9315
`J9320
`J9328
`J9330
`J9351
`J9354
`J9355
`J9357
`J9360
`J9370
`J9371
`J9390
`J9395
`J9400
`P9041
`P9045
`P9046
`P9047
`Q0138
`Q0139
`Q0162
`Q0163
`Q0164
`Q0166
`Q0167
`Q0169
`Q0180
`
`Q2035
`
`Q2037
`Q2043
`Q2050
`Q3027
`Q4074
`Q4081
`Q4101
`Q4102
`Q4104
`Q4105
`Q4106
`Q4107
`Q4108
`Q4110
`Q4111
`Q4112
`Q4113
`Q4115
`Q4116
`Q4121
`Q4123
`Q4131
`Q5101
`Q9950
`Q9956
`
`Romidepsin injection
`Streptozocin injection
`Temozolomide injection
`Temsirolimus injection
`Topotecan injection
`Inj, Ado-trastuzumab Emt 1mg
`Trastuzumab injection
`Valrubicin injection
`Vinblastine sulfate inj
`Vincristine sulfate 1 MG inj
`Inj, vincristine sul lip 1 mg
`Vinorelbine tartrate inj
`Injection, Fulvestrant
`Inj, ziv-aflibercept, 1mg
`Albumin (human),5%, 50ml
`Albumin (human), 5%, 250 ml
`Albumin (human), 25%, 20 ml
`Albumin (human), 25%, 50ml
`Ferumoxytol, non-esrd
`Ferumoxytol, esrd use
`Ondansetron oral
`Diphenhydramine HCl 50mg
`Prochlorperazine maleate 5mg
`Granisetron hcl 1 mg oral
`Dronabinol 2.5mg oral
`Promethazine HCl 12.5mg oral
`Dolasetron mesylate oral
`
`1 MG
`1 GM
`1 MG
`1 MG
`0.1 MG
`1 MG
`10 MG
`200 MG
`1 MG
`1 MG
`1 MG
`10 MG
`25 MG
`1 MG
`50 ML
`250 ML
`20 ML
`50 ML
`1 MG
`1 MG
`1 MG
`50 MG
`5 MG
`1 MG
`2.5 MG
`12.5 MG
`100 MG
`
`306.787
`323.601
`8.242
`66.674
`3.056
`29.215
`92.091
`1148.727
`3.541
`4.246
`2506.488
`10.346
`95.774
`8.446
`11.020
`54.720
`22.488
`53.438
`0.883
`0.883
`1.009
`0.266
`0.040
`0.411
`2.463
`0.021
`94.760
`
`Afluria vacc, 3 yrs & >, im
`
`0.5 ml
`
`16.284
`
`Fluvirin vacc, 3 yrs & >, im
`Sipuleucel-T auto CD54+
`Doxorubicin inj 10mg
`Inj beta interferon im 1 mcg
`Iloprost non-comp unit dose
`Epoetin alfa, 100 units ESRD
`Apligraf skin sub
`Oasis wound 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
`Alloskin
`Alloderm skin sub
`Theraskin
`Alloskin RT
`Epifix
`Inj filgrastim g-csf biosim
`Inj sulf hexa lipid microsph
`Inj octafluoropropane mic,ml
`
`
`
`0.5 ML
`fusion (minimum 50 million
`10 MG
`1 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 CC
`1 CC
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 MCG
`1 ML
`1 ML
`
`16.284
`38034.649
`435.442
`45.372
`123.932
`1.259
`31.022
`11.010
`34.258
`16.573
`33.441
`88.334
`37.631
`50.720
`6.880
`223.468
`223.468
`9.976
`32.202
`42.709
`20.060
`169.401
`0.828
`22.329
`34.549
`
`95
`
`95
`95
`
`58.130
`
`4.100
`33.980
`
`95
`95
`95
`95
`
`11.020
`54.720
`22.488
`53.438
`
`95
`
`95
`
`16.284
`
`16.284
`
`AMP-based payment limit
`AMP-based payment limit
`
`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
`updated January 2017
`
`updated July 2017
`updated July 2017
`
`updated July 2017
`
`Exhibit 2236
`Page 10 of 11
`
`

`

`Q9957
`Q9958
`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`
`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
`
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`
`51.824
`0.077
`0.225
`0.202
`0.195
`0.853
`0.179
`0.124
`
`Exhibit 2236
`Page 11 of 11
`
`