Payment Allowance Limits for Medicare Part B Drugs
`
`Effective October 1, 2017 through December 31, 2017
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q17 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
`90371
`90375
`90376
`90585
`90586
`
`Short Description
`Hep b ig im
`Rabies ig im/sc
`Rabies ig heat treated
`Bcg vaccine percut
`Bcg vaccine intravesical
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`50 MG
`1 EACH
`
`Payment Limit
`124.273
`314.271
`317.428
`131.252
`131.252
`
`Vaccine
`AWP% Vaccine Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`90630
`90632
`
`90653
`
`90656
`
`90662
`90670
`
`90673
`
`90674
`90675
`
`Flu vacc iiv4 no preserv id
`Hepa vaccine adult im
`
`Iiv adjuvant vaccine im
`
`Iiv3 vacc no prsv 0.5 ml im
`
`Iiv no prsv increased ag im
`Pcv13 vaccine im
`
`Riv3 vaccine no preserv im
`
`Cciiv4 vac no prsv 0.5 ml im
`Rabies vaccine im
`
`0.1 ml
`1 ML
`
`0.5 ml
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.5 ML
`
`0.5 ML
`1 ML
`
`90682
`
`RIV4 VACC RECOMBINANT DNA IM
`
`0.5 ML
`
`90685
`
`90686
`
`90687
`
`90688
`
`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
`
`0.25 mL
`
`0.5 ml
`
`0.25 ML
`
`0.5 ML
`
`20.343
`53.385
`
`50.217
`
`19.247
`
`49.025
`192.637
`
`40.613
`
`24.047
`269.123
`
`46.313
`
`21.198
`
`19.032
`
`9.403
`
`17.835
`
`95
`
`95
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`20.343
`
`50.217
`
`19.247
`
`49.025
`192.637
`
`40.613
`
`24.047
`
`46.313
`
`21.198
`
`19.032
`
`9.403
`
`17.835
`
`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 2017
`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 2237
`Page 01 of 11
`
`

`

`95
`95
`95
`95
`95
`95
`
`95
`
`98.849
`126.597
`26.135
`26.135
`63.299
`126.597
`
`22.793
`
`Added October 2017
`see the Seasonal Influenza Vaccines
`Pricing webpage for current payment limits
`and effective dates
`
`microCurie 100% AWP = $154.670
`microCurie 100% WAC = $128.890
`
`90691
`90714
`90715
`90732
`90740
`90743
`90744
`90746
`90747
`
`90756
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9585
`
`A9606
`J0129
`J0130
`J0132
`J0133
`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
`
`Typhoid vaccine im
`Td vacc no presv 7 yrs+ im
`Tdap vaccine 7 yrs/> im
`Ppsv23 vacc 2 yrs+ subq/im
`Hepb vacc 3 dose immunsup im
`Hepb vacc 2 dose adolesc im
`Hepb vacc 3 dose ped/adol im
`Hepb vaccine 3 dose adult im
`Hepb vacc 4 dose immunsup im
`
`CCIIV4 VACC ABX FREE IM
`Inj gadoterate meglumi 0.1ml
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base mr contrast nos,1ml
`Gadoxetate disodium inj
`Gadobutrol injection
`
`Radium ra223 dichloride ther
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir 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 aripiprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 mg injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`40 MCG
`1 DOSE
`1 DOSE
`20 MCG
`40 MCG
`
`0.5 ML
`0.1 ml
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`
`1 microCurie
`10 MG
`10 MG
`100 MG
`5 MG
`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
`
`82.163
`22.073
`31.667
`98.849
`126.597
`26.135
`26.135
`63.299
`126.597
`
`22.793
`0.224
`1.729
`2.080
`1.992
`1.985
`13.938
`0.378
`
`N/A
`49.589
`1215.197
`1.227
`0.072
`0.605
`0.813
`974.587
`171.065
`1778.597
`959.810
`159.734
`4.937
`4.569
`1.632
`9.217
`32.783
`13.859
`21.515
`1.108
`2.972
`0.536
`3.264
`4.886
`3.368
`0.052
`52.694
`164.619
`70.337
`3440.367
`3.935
`42.808
`74.943
`
`Exhibit 2237
`Page 02 of 11
`
`

`

`Added October 2017
`
`AMP-based payment limit
`
`J0515
`J0558
`J0561
`J0570
`J0583
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0596
`J0597
`J0598
`J0600
`J0610
`J0630
`J0636
`J0637
`J0638
`J0640
`J0641
`J0670
`J0690
`J0692
`J0694
`J0696
`J0697
`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
`
`Inj benztropine mesylate
`Peng benzathine/procaine inj
`Penicillin g benzathine inj
`Buprenorphine implant 74.2mg
`Bivalirudin
`Injection,onabotulinumtoxina
`Abobotulinumtoxina
`Inj, rimabotulinumtoxinb
`Incobotulinumtoxin a
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`Injection, ruconest
`C-1 esterase, berinert
`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
`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
`
`1 MG
`100,000 UNITS
`100,000 UNITS
`74.2 MG
`1 MG
`1 UNIT
`5 Unit
`100 UNITS
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`10 UNITS
`10 UNITS
`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
`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
`
`20.220
`9.337
`11.921
`1261.308
`1.227
`6.031
`8.261
`11.978
`5.082
`3.450
`34.725
`2.549
`27.987
`48.973
`57.210
`5594.422
`2.984
`2287.942
`0.657
`12.461
`106.118
`3.233
`0.532
`2.662
`0.859
`2.889
`5.852
`0.657
`2.696
`8.176
`2.625
`2.393
`7.467
`39.425
`20.534
`12.147
`477.545
`5.619
`1.292
`14.378
`41.833
`9.768
`8.614
`3771.358
`43.055
`2870.724
`1128.705
`14.400
`0.618
`3.954
`3.954
`12.942
`1.628
`1.628
`17.703
`8.035
`
`Exhibit 2237
`Page 03 of 11
`
`

`

`J0897
`J1000
`J1020
`J1030
`J1040
`J1050
`J1071
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`J1170
`J1190
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`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
`
`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
`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
`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
`
`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
`4 MG
`250 MG
`50 MG
`500 MG
`50 ML
`10 MG
`50 MG
`10 MG
`250 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
`
`17.332
`19.537
`5.592
`6.362
`12.260
`0.496
`0.025
`0.124
`105.618
`21.248
`8.400
`3267.026
`0.598
`2.046
`185.892
`0.605
`60.935
`554.155
`19.251
`7.442
`0.798
`5.600
`0.635
`0.707
`0.428
`441.288
`226.628
`15.566
`52.338
`64.899
`9.998
`304.606
`443.682
`1.062
`1.007
`0.627
`4.852
`2.025
`380.500
`38.506
`31.764
`38.310
`41.079
`9.813
`317.637
`38.944
`34.282
`36.618
`39.783
`68.489
`61.120
`29.836
`13.136
`1.554
`24.736
`205.553
`
`Exhibit 2237
`Page 04 of 11
`
`

`

`J1626
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`J1720
`J1740
`J1742
`J1743
`J1745
`J1750
`J1756
`J1786
`J1800
`J1815
`J1817
`J1885
`J1930
`J1931
`J1940
`J1942
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2185
`J2210
`J2248
`J2250
`J2260
`J2270
`J2274
`J2278
`J2280
`J2300
`J2310
`J2315
`J2323
`J2353
`J2354
`J2355
`J2357
`J2358
`J2360
`
`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
`Ibutilide fumarate injection
`Idursulfase injection
`Infliximab not biosimil 10mg
`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
`Aripiprazole lauroxil 1mg
`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
`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
`
`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
`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
`1 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
`10 MG
`1 MCG
`100 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`25 MCG
`5 MG
`5 MG
`1 MG
`60 MG
`
`0.363
`1.205
`18.141
`24.000
`0.186
`0.201
`15.274
`0.800
`2.087
`557.454
`11.279
`82.872
`169.137
`542.859
`87.149
`13.043
`0.256
`41.689
`1.615
`0.848
`9.968
`0.558
`55.984
`30.612
`1.054
`2.458
`1087.909
`0.115
`22.077
`1.180
`27.621
`0.018
`12.583
`13.912
`0.741
`2.047
`5.101
`1.332
`16.105
`0.942
`0.112
`1.944
`1.416
`12.400
`7.419
`8.305
`2.703
`28.827
`3.262
`19.415
`183.640
`0.955
`467.216
`34.932
`2.917
`6.907
`
`Exhibit 2237
`Page 05 of 11
`
`

`

`AMP-based payment limit
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`J2400
`J2405
`J2407
`J2410
`J2425
`J2426
`J2430
`J2469
`J2501
`J2503
`J2504
`J2505
`J2507
`J2510
`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
`
`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
`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
`
`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
`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
`
`23.211
`0.088
`23.364
`2.849
`19.204
`10.015
`8.420
`20.899
`1.098
`729.472
`352.273
`4320.732
`2006.661
`29.295
`52.401
`1.050
`2.960
`115.201
`2.174
`35.859
`314.438
`12.752
`1.463
`18.709
`72.649
`1.695
`0.119
`0.912
`15.129
`0.905
`428.618
`378.353
`6.768
`263.063
`55.413
`24.708
`79.069
`4.814
`23.796
`8.625
`0.074
`66.857
`37.236
`105.544
`0.304
`37.702
`34.781
`2.132
`4.337
`6.093
`83.991
`15.366
`0.499
`40.369
`71.465
`1.326
`
`Exhibit 2237
`Page 06 of 11
`
`

`

`J3095
`J3101
`J3105
`J3121
`J3230
`J3240
`J3243
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`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
`
`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
`Triptorelin pamoate
`Ustekinumab sub cu inj, 1 mg
`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 alprolix recomb
`
`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
`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
`
`5.115
`111.696
`3.416
`0.040
`28.043
`1579.688
`2.986
`29.980
`2.543
`4.370
`61.237
`3.884
`1.879
`391.110
`187.258
`9.163
`2.753
`18.590
`342.348
`10.761
`8.506
`3.030
`10.321
`2.093
`4.147
`2.697
`0.390
`0.357
`0.545
`0.120
`1.515
`22.177
`14.984
`2.206
`1.104
`0.889
`0.548
`2.065
`3.903
`2.393
`8.211
`1.294
`1.035
`1.251
`0.981
`1.088
`2.001
`1.018
`1.244
`1.142
`1.386
`1.503
`3.745
`1.937
`1.271
`2.987
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`1
`1
`1
`
`Exhibit 2237
`Page 07 of 11
`
`

`

`1
`
`AMP-based payment limit
`
`J7205
`J7308
`J7311
`J7312
`J7313
`J7316
`J7320
`J7321
`J7323
`J7324
`J7325
`J7326
`J7327
`J7336
`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
`
`Factor viii fc fusion recomb
`Aminolevulinic acid hcl top
`Fluocinolone acetonide implt
`Dexamethasone intra implant
`Fluocinol acet intravit imp
`Inj, ocriplasmin, 0.125 mg
`Genvisc 850, inj, 1mg
`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
`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
`
`1 IU
`354 MG
`0.59 MG
`0.1 MG
`0.01 MG
`0.125 MG
`1 MG
`per dose
`per dose
`per dose
`1 MG
`per dose
`Per Dose
`1 SQ CM
`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
`
`2.023
`367.809
`20114.347
`200.738
`490.801
`1046.750
`7.420
`87.643
`155.230
`149.482
`12.272
`510.570
`856.785
`3.150
`0.268
`2.579
`1.235
`1817.043
`0.609
`0.432
`0.340
`0.081
`710.345
`0.010
`0.780
`41.963
`0.928
`2.673
`7.738
`188.317
`8.138
`9.131
`10.764
`5.083
`0.144
`0.211
`0.047
`0.049
`0.136
`3.236
`0.763
`45.470
`0.220
`0.535
`38.377
`557.079
`7.661
`24.829
`2.246
`6.683
`3.275
`0.083
`74.182
`11.721
`0.471
`458.473
`
`Exhibit 2237
`Page 08 of 11
`
`

`

`J8700
`J8705
`J9000
`J9017
`J9019
`J9025
`J9027
`J9031
`J9032
`J9033
`J9034
`J9035
`J9039
`J9040
`J9041
`J9042
`J9043
`J9045
`J9047
`J9050
`J9055
`J9060
`J9065
`J9070
`J9098
`J9100
`J9120
`J9130
`J9145
`J9150
`J9155
`J9171
`J9176
`J9178
`J9179
`J9181
`J9185
`J9190
`J9200
`J9201
`J9202
`J9205
`J9206
`J9207
`J9208
`J9209
`J9211
`J9214
`J9217
`J9218
`J9225
`J9226
`J9228
`J9230
`J9245
`J9250
`
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Arsenic trioxide injection
`Erwinaze injection
`Azacitidine injection
`Clofarabine injection
`Bcg live intravesical vac
`Injection, belinostat, 10mg
`Inj., treanda 1 mg
`Inj., bendeka 1 mg
`Bevacizumab injection
`Injection, blinatumomab
`Bleomycin sulfate injection
`Bortezomib injection
`Brentuximab vedotin inj
`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
`Injection, daratumumab 10 mg
`Daunorubicin injection
`Degarelix injection
`Docetaxel injection
`Injection, elotuzumab, 1mg
`Inj, epirubicin hcl, 2 mg
`Eribulin mesylate injection
`Etoposide injection
`Fludarabine phosphate inj
`Fluorouracil injection
`Floxuridine injection
`Gemcitabine hcl injection
`Goserelin acetate implant
`Inj irinotecan liposome 1 mg
`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
`
`5 MG
`0.25 mg
`10 MG
`1 MG
`1,000 IU
`1 MG
`1 MG
`1 EA
`10 MG
`1 MG
`1 MG
`10 MG
`1 MCG
`15 UNITS
`0.1 MG
`1 MG
`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
`10 MG
`1 MG
`1 MG
`1 MG
`2 MG
`0.1 MG
`10 MG
`50 MG
`500 MG
`500 MG
`200 MG
`3.6 MG
`1 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
`
`1.462
`103.628
`2.978
`71.337
`402.743
`1.657
`149.956
`131.252
`35.206
`29.189
`23.765
`75.177
`103.429
`37.181
`46.873
`139.386
`159.095
`3.481
`33.161
`3863.469
`57.619
`2.078
`20.662
`42.059
`641.670
`0.816
`1404.012
`3.882
`49.148
`37.860
`3.635
`1.891
`6.262
`1.430
`109.163
`0.501
`104.887
`1.624
`72.674
`5.819
`351.525
`41.132
`3.389
`74.096
`26.850
`2.145
`39.474
`31.706
`209.709
`25.972
`3284.123
`29003.674
`146.780
`292.478
`1369.461
`0.248
`
`Exhibit 2237
`Page 09 of 11
`
`

`

`J9260
`J9261
`J9263
`J9264
`J9266
`J9267
`J9268
`J9271
`J9280
`J9293
`J9295
`J9299
`J9301
`J9302
`J9303
`J9305
`J9306
`J9307
`J9308
`J9310
`J9315
`J9320
`J9325
`J9328
`J9330
`J9351
`J9352
`J9354
`J9355
`J9357
`J9360
`J9370
`J9371
`J9390
`J9395
`J9400
`P9041
`P9045
`P9046
`P9047
`Q0138
`Q0139
`Q0162
`Q0163
`Q0164
`Q0166
`Q0167
`Q0169
`
`Q2035
`
`Q2037
`Q2043
`Q2050
`
`Methotrexate sodium inj
`Nelarabine injection
`Oxaliplatin
`Paclitaxel protein bound
`Pegaspargase injection
`Paclitaxel injection
`Pentostatin injection
`Inj pembrolizumab
`Mitomycin injection
`Mitoxantrone hydrochl / 5 mg
`Injection, necitumumab, 1 mg
`Injection, nivolumab
`Obinutuzumab inj
`Ofatumumab injection
`Panitumumab injection
`Pemetrexed injection
`Injection, pertuzumab, 1 mg
`Pralatrexate injection
`Injection, ramucirumab
`Rituximab injection
`Romidepsin injection
`Streptozocin injection
`Inj talimogene laherparepvec
`Temozolomide injection
`Temsirolimus injection
`Topotecan injection
`Injection trabectedin 0.1mg
`Inj, ado-trastuzumab emt 1mg
`Trastuzumab injection
`Valrubicin injection
`Vinblastine sulfate inj
`Vincristine sulfate 1 mg inj
`Inj, vincristine sul lip 1mg
`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
`
`50 MG
`50 MG
`0.5 MG
`1 MG
`1 EA
`1 MG
`10 MG
`1 MG
`5 MG
`5 MG
`1 MG
`1 MG
`10 MG
`10 MG
`10 MG
`10 MG
`1 MG
`1 MG
`5 MG
`100 MG
`1 MG
`1 GM
`1 million PFU
`1 MG
`1 MG
`0.1 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
`
`2.483
`151.658
`0.194
`10.777
`13907.578
`0.118
`2001.257
`47.965
`133.654
`38.980
`5.289
`26.804
`58.944
`54.907
`110.278
`64.978
`11.156
`247.970
`56.534
`848.408
`328.832
`322.729
`47.210
`9.699
`70.508
`1.247
`289.167
`29.814
`97.803
`1198.557
`3.477
`4.981
`2701.777
`9.293
`96.767
`8.153
`11.799
`54.720
`22.488
`53.438
`0.908
`0.908
`0.030
`0.267
`0.042
`3.511
`4.255
`0.031
`
`Afluria vacc, 3 yrs & >, im
`
`0.5 ml
`
`17.685
`
`Fluvirin vacc, 3 yrs & >, im
`Sipuleucel-t auto cd54+
`Doxorubicin inj 10mg
`
`0.5 ML
` usion (minimum 50 million
`10 MG
`
`17.685
`40440.171
`374.931
`
`95
`
`95
`
`17.685
`
`17.685
`
`95
`95
`95
`95
`
`11.799
`54.720
`22.488
`53.438
`
`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
`
`Exhibit 2237
`Page 10 of 11
`
`

`

`Q3027
`Q4074
`Q4081
`Q4101
`Q4102
`Q4106
`Q4107
`Q4111
`Q4112
`Q4113
`Q4115
`Q4116
`Q4121
`Q4123
`Q4131
`Q4132
`Q4133
`Q5101
`Q5102
`Q9950
`Q9956
`Q9957
`Q9958
`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`Q9989
`
`Inj beta interferon im 1 mcg
`Iloprost non-comp unit dose
`Epoetin alfa, 100 units esrd
`Apligraf
`Oasis wound matrix
`Dermagraft
`Graftjacket
`Gammagraft
`Cymetra injectable
`Graftjacket xpress
`Alloskin
`Alloderm
`Theraskin
`Alloskin
`Epifix or epicord
`Grafix core
`Grafix prime
`Inj filgrastim gcsf biosimil
`Inj., infliximab biosimilar
`Inj sulf hexa lipid microsph
`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
`Ustekinumab IV Inj, 1 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 CC
`1 CC
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 MCG
`10 MG
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 MG
`
`50.112
`130.260
`1.294
`30.898
`10.989
`33.234
`95.593
`6.979
`203.344
`203.344
`9.317
`31.701
`45.615
`26.924
`165.180
`138.938
`138.877
`0.715
`78.724
`21.246
`33.986
`50.978
`0.077
`0.173
`0.260
`0.212
`0.821
`0.329
`0.123
`12.882
`
`Exhibit 2237
`Page 11 of 11
`
`