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
`
`Vaccine
`AWP% Vaccine Limit
`
`Infusion
`AWP%
`
`DME Infusion
`Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`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
`
`90687
`
`90688
`90691
`90703
`90714
`90715
`90732
`90733
`90740
`90743
`90744
`90746
`90747
`A9575
`A9576
`A9577
`
`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
`
`Flu vac no prsv 4 val 6-35 m
`
`Flu vac no prsv 4 val 3 yrs+
`
`Flu vaccine, 6-35 mon, IM, 4 val
`
`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
`
`0.5 ML
`
`0.5 ML
`0.5 ML
`
`0.2 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
`0.5 ML
`0.5 ML
`40 MCG
`1 DOSE
`1 DOSE
`20 MCG
`40 MCG
`0.1 ml
`1 ML
`1 ML
`
`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
`
`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
`
`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
`
`Exhibit 2240
`Page 01 of 09
`
`

`

`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
`J0588
`J0592
`J0594
`J0595
`J0597
`J0598
`J0600
`J0610
`J0630
`J0636
`J0637
`J0638
`J0640
`J0641
`J0670
`J0690
`J0692
`
`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
`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
`Caspofungin acetate
`Canakinumab injection
`Leucovorin calcium injection
`Levoleucovorin injection
`Inj mepivacaine HCL/10 ml
`Cefazolin sodium injection
`Cefepime HCl for injection
`
`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
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`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
`
`1.747
`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
`4.480
`3.063
`28.937
`1.756
`37.635
`51.863
`3477.508
`1.272
`69.292
`0.385
`11.836
`90.960
`3.736
`1.770
`2.196
`1.186
`2.396
`
`95
`95
`95
`
`10.280
`21.850
`35.800
`
`95
`95
`
`215.180
`79.800
`
`Exhibit 2240
`Page 02 of 09
`
`

`

`updated October 2015
`
`updated January 2015
`
`updated April 2015
`updated April 2015
`
`J0694
`J0696
`J0697
`J0698
`J0702
`J0712
`J0713
`J0717
`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
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1260
`J1265
`J1267
`J1270
`J1290
`J1300
`J1325
`J1335
`J1364
`J1380
`J1410
`J1430
`J1438
`J1442
`
`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
`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
`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
`Etanercept injection
`Inj, Filgrastim G-CSF 1mcg
`
`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
`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
`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
`25 MG
`1 MCG
`
`4.990
`0.697
`2.790
`1.813
`5.710
`1.129
`2.098
`6.170
`31.736
`18.069
`19.165
`588.097
`4.826
`1.097
`11.501
`38.481
`9.357
`7.724
`3324.923
`51.358
`2493.120
`1013.869
`0.670
`3.761
`3.761
`11.653
`11.653
`28.250
`8.663
`14.446
`10.348
`3.484
`3.249
`6.241
`0.280
`4.941
`4.972
`0.142
`65.268
`22.388
`5.536
`2051.630
`0.530
`1.834
`144.864
`0.534
`122.652
`83.539
`8.495
`5.320
`0.819
`5.301
`6.187
`0.573
`0.627
`1.463
`375.642
`206.135
`15.459
`35.275
`45.007
`9.550
`180.139
`311.058
`285.273
`0.991
`
`95
`
`15.630
`
`95
`
`95
`
`95
`
`1.490
`
`0.750
`
`4.740
`
`95
`
`12.640
`
`Exhibit 2240
`Page 03 of 09
`
`

`

`J1446
`J1450
`J1453
`J1458
`J1459
`J1460
`J1556
`J1557
`J1559
`J1560
`J1561
`J1566
`J1568
`J1569
`J1570
`J1571
`J1572
`J1580
`J1602
`J1610
`J1626
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`J1720
`J1740
`J1742
`J1743
`J1745
`J1750
`J1756
`J1786
`J1790
`J1800
`J1815
`J1817
`J1840
`J1850
`J1885
`J1930
`J1931
`J1940
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2185
`J2210
`J2248
`J2250
`J2260
`J2270
`J2278
`
`Inj., tbo-Filgrastim, 5 mcg
`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
`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
`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
`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
`Ziconotide injection
`
`5 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
`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
`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
`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
`1 MCG
`
`3.994
`4.223
`1.727
`359.120
`37.026
`28.767
`36.206
`35.836
`7.940
`287.671
`40.021
`26.753
`36.923
`39.360
`72.113
`53.698
`37.755
`1.233
`24.156
`146.069
`0.247
`1.982
`18.979
`20.732
`0.173
`0.206
`14.223
`1.465
`3.926
`326.321
`6.081
`151.800
`112.297
`483.047
`74.341
`12.161
`0.276
`42.007
`2.141
`2.417
`0.427
`5.306
`7.685
`1.153
`0.286
`41.395
`29.447
`5.329
`829.724
`0.124
`7.995
`2.340
`18.526
`0.020
`9.051
`45.664
`0.710
`2.100
`4.984
`1.142
`5.031
`0.977
`0.135
`3.780
`1.315
`6.871
`
`95
`
`35.250
`
`95
`
`2.800
`
`95
`
`95
`95
`
`0.560
`
`51.580
`0.710
`
`AMP-based payment limit
`
`Exhibit 2240
`Page 04 of 09
`
`

`

`J2280
`J2300
`J2310
`J2315
`J2323
`J2353
`J2354
`J2355
`J2357
`J2358
`J2360
`J2370
`J2400
`J2405
`J2410
`J2425
`J2426
`J2430
`J2469
`J2501
`J2503
`J2504
`J2505
`J2507
`J2510
`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2562
`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
`J3010
`
`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
`Phenylephrine hcl injection
`Chloroprocaine hcl injection
`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
`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
`Fentanyl citrate injeciton
`
`100 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`25 MCG
`5 MG
`5 MG
`1 MG
`60 MG
`1 ML
`30 ML
`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
`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
`0.1 MG
`
`5.328
`2.492
`42.751
`2.875
`14.909
`141.871
`1.141
`321.879
`27.850
`2.753
`6.488
`3.241
`19.347
`0.080
`2.903
`14.848
`7.909
`11.362
`20.005
`1.788
`1034.024
`281.400
`3387.927
`856.636
`17.063
`35.820
`0.737
`1.477
`93.248
`1.572
`21.135
`301.196
`5.076
`0.915
`23.998
`49.936
`1.762
`1.041
`14.515
`89.163
`113.401
`0.698
`245.219
`396.427
`1.211
`218.751
`52.747
`25.455
`84.269
`4.796
`18.851
`6.161
`0.120
`53.628
`42.099
`87.025
`0.313
`30.127
`34.781
`2.561
`1.943
`2.865
`2301.907
`64.296
`12.900
`0.521
`
`updated April 2015
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`95
`
`0.700
`
`Exhibit 2240
`Page 05 of 09
`
`

`

`J3060
`J3070
`J3095
`J3101
`J3105
`J3120
`J3130
`J3230
`J3240
`J3243
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`J3303
`J3315
`J3357
`J3360
`J3370
`J3385
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`J3473
`J3475
`J3480
`J3485
`J3486
`J3489
`J7030
`J7040
`J7042
`J7050
`J7060
`J7070
`J7100
`J7120
`J7180
`J7183
`J7185
`J7186
`J7187
`J7189
`J7190
`J7192
`J7193
`J7194
`J7195
`J7197
`J7198
`J7308
`J7310
`J7311
`J7312
`J7316
`J7321
`J7323
`J7324
`J7325
`J7326
`
`Inj, Taliglucerace Alfa 10 u
`Pentazocine injection
`Telavancin injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Testosterone enanthate inj
`Testosterone enanthate inj
`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
`Triptorelin pamoate
`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 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
`Dextran 40 infusion
`Ringers lactate infusion
`Factor xiii anti-hem factor
`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
`Antithrombin iii injection
`Anti-inhibitor
`Aminolevulinic acid hcl top
`Ganciclovir long act implant
`Fluocinolone acetonide implt
`Dexamethasone intra implant
`Inj, Ocriplasmin, 0.125 mg
`Hyalgan/supartz inj per dose
`Euflexxa inj per dose
`Orthovisc inj per dose
`Synvisc or Synvisc-One
`Gel-One
`
`10 UNITS
`30 MG
`10 MG
`1 MG
`1 MG
`100 MG
`200 MG
`50 MG
`0.9 MG
`1 MG
`200 MG
`80 MG
`1 MG
`1 MG
`1 MG
`10 MG
`5 MG
`3.75 MG
`1 MG
`5 MG
`500 MG
`100 UNITS
`0.1 MG
`25 MG
`100 MG
`100 MG
`1000 MCG
`1 MG
`10 MG
`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
`500 ML
`1000 CC
`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
`354 MG
`4.5 MG
`0.59 MG
`0.1 MG
`0.125 MG
`per dose
`per dose
`per dose
`1 MG
`per dose
`
`31.941
`140.116
`4.515
`86.210
`4.086
`7.204
`8.909
`23.016
`1430.434
`1.998
`19.702
`2.458
`3.683
`61.237
`3.727
`1.765
`2.390
`170.770
`162.285
`4.794
`2.175
`353.350
`10.788
`0.451
`3.454
`6.986
`1.820
`1.226
`3.972
`0.333
`0.186
`0.122
`1.498
`11.732
`47.477
`1.351
`0.675
`0.596
`0.338
`1.183
`2.324
`21.588
`1.164
`6.736
`0.951
`1.169
`0.935
`0.953
`1.731
`0.932
`1.135
`1.014
`1.123
`1.351
`3.265
`1.701
`242.295
`16960.000
`19641.051
`201.306
`1046.750
`90.813
`161.120
`186.888
`12.502
`562.076
`
`AMP-based payment limit
`
`updated April 2015
`
`AMP-based payment limit
`
`added October 2014
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`1
`
`updated January 2015
`
`Exhibit 2240
`Page 06 of 09
`
`

`

`J7335
`J7500
`J7501
`J7502
`J7504
`J7506
`J7507
`J7508
`J7509
`J7510
`J7511
`J7515
`J7516
`J7517
`J7518
`J7520
`J7525
`J7527
`J7605
`J7606
`J7608
`J7611
`J7612
`J7613
`J7614
`J7620
`J7626
`J7631
`J7639
`J7644
`J7665
`J7674
`J7682
`J7686
`J8501
`J8510
`J8520
`J8521
`J8530
`J8540
`J8560
`J8600
`J8610
`J8700
`J8705
`J9000
`J9015
`J9017
`J9019
`J9020
`J9025
`J9027
`J9031
`J9033
`J9035
`J9040
`J9041
`J9042
`J9043
`J9045
`J9047
`J9050
`J9055
`J9060
`J9065
`J9070
`
`Capsaicin 8% patch
`Azathioprine oral 50mg
`Azathioprine parenteral
`Cyclosporine oral 100 mg
`Lymphocyte immune globulin
`Prednisone oral
`Tacrolimus Imme Rel oral 1mg
`Tacrolimus Ex Rel oral 0.1mg
`Methylprednisolone oral
`Prednisolone oral per 5 mg
`Antithymocyte globuln rabbit
`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
`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
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Aldesleukin 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
`Injection, Carfilzomib, 1 mg
`Carmustine injection
`Cetuximab injection
`Cisplatin 10 MG injection
`Inj cladribine per 1 MG
`Cyclophosphamide 100 MG inj
`
`10 SQ CM
`50 MG
`100 MG
`100 MG
`250 MG
`5 MG
`1 MG
`0.1 MG
`4 MG
`5 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
`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
`5 MG
`0.25 mg
`10 MG
`1 EA
`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
`1 MG
`100 MG
`10 MG
`10 MG
`1 MG
`100 MG
`
`26.497
`0.190
`217.300
`3.376
`852.686
`0.078
`1.197
`0.395
`0.601
`0.091
`594.740
`0.879
`33.838
`1.529
`3.405
`16.226
`141.104
`6.852
`6.696
`7.459
`3.704
`0.114
`0.192
`0.056
`0.098
`0.171
`5.377
`0.463
`35.753
`0.237
`0.669
`0.515
`95.958
`482.998
`7.676
`10.982
`8.674
`28.631
`1.073
`0.195
`57.087
`9.416
`1.084
`5.385
`94.739
`3.004
`2110.630
`53.583
`354.755
`64.565
`3.918
`134.103
`121.959
`22.212
`66.653
`20.716
`46.081
`110.820
`142.424
`3.454
`29.810
`1861.116
`53.287
`2.038
`21.209
`63.159
`
`95
`
`289.370
`
`95
`
`61.720
`
`updated April 2015
`
`updated April 2015
`
`updated April 2015
`
`updated April 2015
`AMP-based payment limit
`
`updated April 2015
`
`Exhibit 2240
`Page 07 of 09
`
`

`

`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
`J9265
`J9266
`J9268
`J9280
`J9293
`J9302
`J9303
`J9305
`J9306
`J9307
`J9310
`J9315
`J9320
`J9328
`J9330
`J9351
`J9354
`J9355
`J9357
`J9360
`J9370
`J9371
`J9390
`J9395
`J9400
`P9041
`P9045
`P9046
`P9047
`Q0138
`Q0139
`Q0162
`Q0163
`
`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
`Paclitaxel injection
`Pegaspargase injection
`Pentostatin injection
`Mitomycin injection
`Mitoxantrone hydrochl / 5 MG
`Ofatumumab injection
`Panitumumab injection
`Pemetrexed injection
`Injection, Pertuzumab, 1 mg
`Pralatrexate injection
`Rituximab injection
`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
`
`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
`30 MG
`1 EA
`10 MG
`5 MG
`5 MG
`10 MG
`10 MG
`10 MG
`1 MG
`1 MG
`100 MG
`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
`
`561.391
`0.935
`807.190
`3.637
`22.558
`3.545
`4.586
`1.347
`99.006
`0.680
`70.981
`2.057
`55.652
`6.655
`225.022
`4.195
`70.211
`33.412
`2.837
`49.106
`21.174
`229.255
`7.184
`3001.589
`18317.235
`133.609
`189.629
`1226.630
`0.211
`2.105
`138.872
`0.575
`9.703
`3.818
`6220.797
`1483.274
`20.878
`32.340
`47.755
`94.788
`60.265
`10.218
`197.122
`708.680
`270.641
`335.278
`5.683
`58.830
`1.827
`29.144
`82.490
`1085.290
`2.711
`4.908
`2148.204
`10.874
`91.272
`8.123
`10.908
`54.540
`22.488
`53.438
`0.743
`0.743
`0.066
`0.213
`
`updated April 2015
`
`AMP-based payment limit
`
`updated April 2015
`
`AMP-based payment limit
`
`95
`
`8.190
`
`95
`95
`
`2.070
`136.800
`
`95
`
`150.380
`
`95
`
`95
`95
`
`58.130
`
`4.100
`33.980
`
`95
`95
`95
`95
`
`10.908
`54.540
`22.488
`53.438
`
`Exhibit 2240
`Page 08 of 09
`
`

`

`Q0164
`Q0166
`Q0167
`Q0169
`Q0180
`
`Q2035
`
`Q2036
`
`Q2037
`
`Q2038
`Q2043
`Q2049
`Q2050
`Q3027
`Q4074
`Q4081
`Q4101
`Q4102
`Q4104
`Q4105
`Q4106
`Q4107
`Q4108
`Q4110
`Q4111
`Q4112
`Q4113
`Q4114
`Q4115
`Q4116
`Q4121
`Q4123
`Q4131
`Q9956
`Q9957
`Q9958
`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`Q9970
`Q9974
`
`Prochlorperazine maleate 5mg
`Granisetron hcl 1 mg oral
`Dronabinol 2.5mg oral
`Promethazine HCl 12.5mg oral
`Dolasetron mesylate oral
`
`Afluria vacc, 3 yrs & >, im
`
`Flulaval vacc, 3 yrs & >, im
`
`Fluvirin vacc, 3 yrs & >, im
`
`5 MG
`1 MG
`2.5 MG
`12.5 MG
`100 MG
`
`0.5 ml
`
`0.5 ML
`
`0.5 ML
`
`0.036
`1.844
`3.708
`0.080
`78.345
`
`11.885
`
`8.579
`
`15.396
`
`Fluzone vacc, 3 yrs & >, im
`Sipuleucel-T auto CD54+
`Imported Lipodox inj
`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
`Integra flowable wound matri
`Alloskin
`Alloderm skin sub
`Theraskin
`Alloskin RT
`Epifix
`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
`Inj Ferric Carboxymaltos 1mg
`Morphine epidural/intratheca
`
`12.044
`0.5 ML
` usion (minimum 50 million 35094.119
`10 MG
`508.429
`10 MG
`490.486
`1 MCG
`36.366
`UP TO 20 MCG
`95.011
`100 UNITS
`1.165
`1 SQ CM
`33.611
`1 SQ CM
`8.871
`1 SQ CM
`21.111
`1 SQ CM
`11.013
`1 SQ CM
`38.596
`1 SQ CM
`99.279
`1 SQ CM
`29.052
`1 SQ CM
`37.223
`1 SQ CM
`6.904
`1 CC
`381.991
`1 CC
`381.991
`1 CC
`1368.405
`1 SQ CM
`7.703
`1 SQ CM
`32.482
`1 SQ CM
`32.416
`1 SQ CM
`15.380
`1 SQ CM
`219.515
`1 ML
`37.240
`1 ML
`55.860
`1 ML
`0.092
`1 ML
`0.174
`1 ML
`0.200
`1 ML
`0.197
`1 ML
`1.120
`1 ML
`0.208
`1 ML
`0.237
`1 MG
`1.049
`10MG
`9.631
`
`95
`
`95
`
`95
`
`95
`
`11.885
`
`8.579
`
`15.396
`
`12.044
`
`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
`
`Exhibit 2240
`Page 09 of 09
`
`