Payment Allowance Limits for Medicare Part B Drugs
`
`Effective October 1, 2020 through December 31, 2020
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q20 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall
`be made by the local Medicare contractor processing the claim.
`
`HCPCS Code
`90371
`90375
`90376
`90586
`90632
`
`90653
`
`90662
`90670
`
`90672
`
`90674
`90675
`
`90682
`
`90685
`
`90686
`
`90687
`
`90688
`90691
`
`90694
`90714
`90715
`90732
`90739
`90740
`90744
`90746
`90747
`
`Short Description
`Hep b ig im
`Rabies ig im/sc
`Rabies ig heat treated
`Bcg vaccine intravesical
`Hepa vaccine adult im
`
`Iiv adjuvant vaccine im
`
`Iiv no prsv increased ag im
`Pcv13 vaccine im
`
`Laiv4 vaccine intranasal
`
`Cciiv4 vac no prsv 0.5 ml im
`Rabies vaccine im
`
`Riv4 vacc recombinant dna 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
`
`Vacc AIIV4 no prsrv 0.5ML IM
`Td vacc no presv 7 yrs+ im
`Tdap vaccine 7 yrs/> im
`Ppsv23 vacc 2 yrs+ subq/im
`Hepb vacc 2 dose adult im
`Hepb vacc 3 dose immunsup im
`Hepb vacc 3 dose ped/adol im
`Hepb vaccine 3 dose adult im
`Hepb vacc 4 dose immunsup im
`
`Vaccine
`AWP%
`
`Vaccine Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`1 EACH
`1 ML
`
`Payment Limit
`119.087
`273.035
`331.803
`139.634
`58.442
`
`0.5 ml
`
`0.5 ML
`0.5 ML
`
`0.2 ML
`
`0.5 ML
`1 ML
`
`0.5 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
`1 dose
`40 MCG
`1 DOSE
`20 MCG
`40 MCG
`
`59.529
`
`60.982
`230.141
`
`26.876
`
`29.228
`303.241
`
`60.982
`
`21.129
`
`19.581
`
`9.584
`
`19.168
`75.163
`
`61.000
`25.269
`34.276
`119.921
`131.100
`140.756
`28.208
`69.648
`140.756
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`95
`95
`95
`95
`
`59.529
`
`60.982
`230.141
`
`26.876
`
`29.228
`
`60.982
`
`21.129
`
`19.581
`
`9.584
`
`19.168
`
`61.000
`
`119.921
`131.100
`140.756
`28.208
`69.648
`140.756
`
`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
`
`Added October 2020 - see the Seasonal
`Influenza Vaccines Pricing webpage for
`current payment limits and effective dates
`
`Exhibit 2241
`Page 01 of 13
`
`

`

`95
`
`27.695
`
`see the Seasonal Influenza Vaccines
`Pricing webpage for current payment limits
`and effective dates
`
`microCurie 100% AWP = $166.020
`microCurie 100% WAC = $138.350
`
`updated April 2021
`updated April 2021
`
`90756
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9585
`A9589
`
`A9606
`J0121
`J0122
`J0129
`J0132
`J0133
`J0153
`J0171
`J0178
`J0179
`J0180
`J0185
`J0202
`J0207
`J0221
`J0222
`J0223
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0291
`J0295
`J0348
`J0360
`J0401
`J0456
`J0461
`J0475
`J0476
`J0480
`J0485
`J0490
`J0500
`J0515
`J0517
`J0558
`J0561
`J0565
`
`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
`Insti hexaminolevulinate hcl
`
`Radium ra223 dichloride ther
`Inj., omadacycline, 1 mg
`Inj., eravacycline, 1 mg
`Abatacept injection
`Acetylcysteine injection
`Acyclovir injection
`Adenosine inj 1mg
`Adrenalin epinephrine inject
`Aflibercept injection
`Inj, brolucizumab-dbll, 1 mg
`Agalsidase beta injection
`Inj., aprepitant, 1 mg
`Injection, alemtuzumab
`Amifostine
`Lumizyme injection
`Inj., patisiran, 0.1 mg
`Inj givosiran 0.5 mg
`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
`Inj., plazomicin, 5 mg
`Ampicillin sulbactam 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Inj aripiprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Baclofen 10 mg injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`Inj., benralizumab, 1 mg
`Peng benzathine/procaine inj
`Penicillin g benzathine inj
`Inj, bezlotoxumab, 10 mg
`
`0.5 ML
`0.1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`100 MG
`
`1 microCurie
`1 MG
`1 MG
`10 MG
`100 MG
`5 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`500 MG
`10 MG
`0.1 MG
`0.5 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`5 MG
`1.5 GM
`1 MG
`20 MG
`1 MG
`500 MG
`0.01 MG
`10 MG
`50 MCG
`20 MG
`1 MG
`10 MG
`20 MG
`1 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`10 MG
`
`27.695
`0.175
`1.502
`1.814
`1.750
`1.527
`14.762
`0.357
`1173.505
`
`N/A
`3.147
`1.018
`58.103
`1.056
`0.053
`0.568
`0.884
`928.241
`311.994
`188.990
`1.732
`1984.320
`1135.691
`174.488
`97.843
`106.875
`4.358
`4.834
`1.302
`9.017
`38.925
`9.358
`26.563
`0.922
`3.105
`2.642
`0.510
`3.375
`5.700
`4.033
`0.085
`172.277
`59.485
`4005.187
`3.775
`46.179
`33.573
`17.265
`170.112
`11.998
`15.158
`39.645
`
`Exhibit 2241
`Page 02 of 13
`
`

`

`J0570
`J0583
`J0584
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0596
`J0597
`J0598
`J0600
`J0610
`J0630
`J0636
`J0637
`J0638
`J0640
`J0641
`J0642
`J0670
`J0690
`J0691
`J0692
`J0694
`J0695
`J0696
`J0697
`J0698
`J0702
`J0712
`J0713
`J0714
`J0717
`J0720
`J0725
`J0735
`J0740
`J0742
`J0743
`J0744
`J0770
`J0775
`J0780
`J0791
`J0795
`J0800
`J0834
`J0840
`J0841
`J0850
`J0875
`
`Buprenorphine implant 74.2mg
`Bivalirudin
`Injection, burosumab-twza 1m
`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
`Inj levoleucovorin nos 0.5mg
`Injection, khapzory, 0.5 mg
`Inj mepivacaine hcl/10 ml
`Cefazolin sodium injection
`Inj lefamulin 1 mg
`Cefepime hcl for injection
`Cefoxitin sodium injection
`Inj ceftolozane tazobactam
`Ceftriaxone sodium injection
`Sterile cefuroxime injection
`Cefotaxime sodium injection
`Betamethasone acet&sod phosp
`Ceftaroline fosamil inj
`Inj ceftazidime per 500 mg
`Ceftazidime and avibactam
`Certolizumab pegol inj 1mg
`Chloramphenicol sodium injec
`Chorionic gonadotropin/1000u
`Clonidine hydrochloride
`Cidofovir injection
`Inj imip 4 cilas 4 releb 2mg
`Cilastatin sodium injection
`Ciprofloxacin iv
`Colistimethate sodium inj
`Collagenase, clost hist inj
`Prochlorperazine injection
`Inj crizanlizumab-tmca 5mg
`Corticorelin ovine triflutal
`Corticotropin injection
`Inj., cosyntropin, 0.25 mg
`Crotalidae poly immune fab
`Inj crotalidae im f(ab')2 eq
`Cytomegalovirus imm iv /vial
`Injection, dalbavancin
`
`74.2 MG
`1 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
`0.5 MG
`10 ML
`500 MG
`1 MG
`500 MG
`1 GM
`75mg (50mg cft/25mg taz)
`250 MG
`750 MG
`1 GM
`3 MG & 3 MG
`10 MG
`500 MG
`.625 GM
`1 MG
`1 GM
`1000 UNITS
`1 MG
`375 MG
`4 MG-4 MG-2 MG
`250 MG
`200 MG
`150 MG
`0.01 MG
`10 MG
`5 MG
`1 MCG
`40 UNITS
`0.25 MG
`UP TO 1 GM
`120 MG
`PER VIAL
`5 MG
`
`1207.160
`0.481
`361.895
`6.077
`8.149
`11.929
`5.019
`4.478
`3.405
`2.886
`29.108
`54.134
`56.199
`5594.422
`3.979
`2839.223
`0.752
`6.871
`113.238
`2.800
`0.280
`1.891
`2.995
`0.968
`0.724
`1.881
`7.360
`6.490
`0.631
`1.941
`2.332
`6.551
`3.322
`1.949
`92.002
`8.161
`32.682
`21.669
`23.262
`666.250
`2.255
`6.329
`1.004
`15.615
`52.388
`5.095
`122.413
`9.377
`4013.242
`39.216
`3043.750
`1264.210
`1496.953
`15.386
`
`Updated January 2021
`
`updated April 2021
`
`AMP-based payment limit
`
`Added October 2020
`
`Exhibit 2241
`Page 03 of 13
`
`

`

`J0878
`J0881
`J0882
`J0885
`J0887
`J0888
`J0894
`J0895
`J0897
`J1000
`J1020
`J1030
`J1040
`J1050
`J1071
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`J1170
`J1190
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1265
`J1270
`J1290
`J1300
`J1301
`J1303
`J1322
`J1325
`J1335
`J1364
`J1380
`J1410
`J1430
`J1439
`J1442
`J1447
`J1450
`J1453
`J1454
`J1458
`J1459
`J1460
`J1555
`J1556
`
`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
`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
`Injection, doxercalciferol
`Ecallantide injection
`Eculizumab injection
`Injection, edaravone, 1 mg
`Inj., ravulizumab-cwvz 10 mg
`Elosulfase alfa, 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
`Inj fosnetupitant, palonoset
`Galsulfase injection
`Inj ivig privigen 500 mg
`Gamma globulin 1 cc inj
`Inj cuvitru, 100 mg
`Inj, imm glob bivigam, 500mg
`
`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
`4 MG
`250 MG
`50 MG
`500 MG
`50 ML
`10 MG
`50 MG
`10 MG
`250 MG
`40 MG
`1 MCG
`1 MG
`10 MG
`1 MG
`10 MG
`1 MG
`0.5 MG
`500 MG
`500 MG
`10 MG
`25 MG
`100 MG
`1 MG
`1 MCG
`1 MCG
`200 MG
`1 MG
`0.25 MG
`1 MG
`500 MG
`1 CC
`100 MG
`500 MG
`
`0.161
`3.716
`3.716
`9.109
`1.544
`1.544
`4.260
`8.440
`20.123
`24.064
`3.462
`5.880
`11.193
`0.556
`0.030
`0.128
`55.966
`21.894
`5.641
`3972.138
`0.496
`1.975
`199.929
`0.650
`54.786
`635.667
`17.554
`6.556
`3.357
`5.693
`0.560
`0.329
`494.686
`230.479
`19.892
`226.275
`246.196
`16.314
`32.799
`76.845
`8.176
`325.621
`444.099
`1.106
`0.925
`0.470
`3.431
`0.785
`695.767
`405.755
`41.503
`42.925
`14.022
`70.490
`
`Exhibit 2241
`Page 04 of 13
`
`

`

`J1557
`J1558
`J1559
`J1560
`J1561
`J1566
`J1568
`J1569
`J1570
`J1571
`J1572
`J1575
`J1580
`J1602
`J1610
`J1626
`J1627
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`J1720
`J1740
`J1742
`J1743
`J1745
`J1746
`J1750
`J1756
`J1786
`J1800
`J1815
`J1817
`J1885
`J1930
`J1931
`J1940
`J1943
`J1944
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`
`Gammaplex injection
`Inj. xembify, 100 mg
`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
`Inj, granisetron, xr, 0.1 mg
`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., ibalizumab-uiyk, 10 mg
`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
`Inj., aristada initio, 1 mg
`Aripirazole lauroxil 1 mg
`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
`
`500 MG
`100 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
`0.1 MG
`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
`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
`1 MG
`3.75 MG
`10 MG
`1 GM
`250 MG
`0.25 MG
`10 MG
`300 MG
`200 MG
`2 MG
`50 ML
`
`53.662
`14.223
`10.855
`429.255
`42.186
`68.303
`41.229
`43.201
`12.842
`63.403
`40.383
`14.486
`1.789
`18.997
`211.789
`0.314
`0.191
`0.909
`14.943
`24.436
`0.014
`0.290
`10.668
`0.688
`1.456
`476.569
`14.151
`50.999
`316.198
`542.917
`47.620
`63.624
`15.010
`0.218
`43.377
`3.990
`0.872
`10.228
`0.671
`68.475
`33.102
`0.787
`2.858
`2.847
`1347.559
`0.122
`20.823
`0.403
`31.595
`0.022
`11.577
`7.505
`0.754
`2.068
`
`Exhibit 2241
`Page 05 of 13
`
`

`

`J2175
`J2182
`J2185
`J2210
`J2248
`J2250
`J2260
`J2270
`J2274
`J2278
`J2280
`J2300
`J2310
`J2315
`J2323
`J2350
`J2353
`J2354
`J2357
`J2358
`J2360
`J2400
`J2405
`J2407
`J2425
`J2426
`J2430
`J2469
`J2501
`J2503
`J2505
`J2507
`J2510
`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2562
`J2597
`J2675
`J2680
`J2690
`J2700
`J2704
`J2720
`J2724
`J2760
`J2765
`J2770
`J2778
`J2780
`J2783
`
`Meperidine hydrochl /100 mg
`Injection, mepolizumab, 1mg
`Meropenem
`Methylergonovin maleate inj
`Micafungin sodium injection
`Inj midazolam hydrochloride
`Inj milrinone lactate / 5 mg
`Morphine sulfate injection
`Inj morphine pf epid ithc
`Ziconotide injection
`Inj, moxifloxacin 100 mg
`Inj nalbuphine hydrochloride
`Inj naloxone hydrochloride
`Naltrexone, depot form
`Natalizumab injection
`Injection, ocrelizumab, 1 mg
`Octreotide injection, depot
`Octreotide inj, non-depot
`Omalizumab injection
`Olanzapine long-acting inj
`Orphenadrine injection
`Chloroprocaine hcl injection
`Ondansetron hcl injection
`Injection, oritavancin
`Palifermin injection
`Paliperidone palmitate inj
`Pamidronate disodium /30 mg
`Palonosetron hcl
`Paricalcitol
`Pegaptanib sodium injection
`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
`Phentolaine mesylate inj
`Metoclopramide hcl injection
`Quinupristin/dalfopristin
`Ranibizumab injection
`Ranitidine hydrochloride inj
`Rasburicase
`
`100 MG
`1 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
`1 MG
`25 MCG
`5 MG
`1 MG
`60 MG
`30 ML
`1 MG
`10 MG
`50 MCG
`1 MG
`30 MG
`25 MCG
`1 MCG
`0.3 MG
`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
`5 MG
`10 MG
`500 MG
`0.1 mg
`25 MG
`0.5 MG
`
`8.354
`28.704
`0.855
`19.565
`1.180
`0.125
`1.511
`1.872
`10.402
`8.171
`9.357
`3.070
`11.032
`3.261
`21.630
`57.383
`205.878
`0.948
`37.699
`2.917
`5.287
`21.601
`0.091
`23.797
`22.812
`12.102
`11.517
`3.775
`0.605
`722.989
`3571.681
`2801.076
`30.530
`33.926
`1.103
`1.653
`119.589
`2.313
`47.334
`365.294
`10.453
`1.427
`10.643
`71.734
`1.301
`0.108
`1.079
`15.064
`359.137
`1.043
`458.041
`324.272
`3.305
`300.937
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`Exhibit 2241
`Page 06 of 13
`
`

`

`J2785
`J2786
`J2788
`J2790
`J2791
`J2792
`J2794
`J2795
`J2796
`J2798
`J2800
`J2805
`J2820
`J2860
`J2916
`J2920
`J2930
`J2997
`J3000
`J3010
`J3060
`J3090
`J3095
`J3101
`J3105
`J3111
`J3121
`J3145
`J3230
`J3240
`J3241
`J3243
`J3245
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`J3304
`J3315
`J3357
`J3358
`J3360
`J3370
`J3380
`J3385
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`
`Regadenoson injection
`Injection, reslizumab, 1mg
`Rho d immune globulin 50 mcg
`Rho d immune globulin inj
`Rhophylac injection
`Rho(d) immune globulin h, sd
`Inj risperdal consta, 0.5 mg
`Ropivacaine hcl injection
`Romiplostim injection
`Inj., perseris, 0.5 mg
`Methocarbamol injection
`Sincalide injection
`Sargramostim injection
`Injection, siltuximab
`Na ferric gluconate complex
`Methylprednisolone injection
`Methylprednisolone injection
`Alteplase recombinant
`Streptomycin injection
`Fentanyl citrate injection
`Inj, taliglucerase alfa 10 u
`Inj tedizolid phosphate
`Telavancin injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Inj. romosozumab-aqqg 1 mg
`Inj testostero enanthate 1mg
`Testosterone undecanoate 1mg
`Chlorpromazine hcl injection
`Thyrotropin injection
`Inj. teprotumumab-trbw 10 mg
`Tigecycline injection
`Inj., tildrakizumab, 1 mg
`Trimethobenzamide hcl inj
`Tobramycin sulfate injection
`Tocilizumab injection
`Treprostinil injection
`Triamcinolone a inj prs-free
`Triamcinolone acet inj nos
`Inj triamcinolone ace xr 1mg
`Triptorelin pamoate
`Ustekinumab sub cu inj, 1 mg
`Ustekinumab, iv inject, 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
`
`0.1 MG
`1 MG
`50 MCG (250 IU)
`300 MCG (1500 IU)
`100 IU
`100 IU
`0.5 MG
`1 MG
`10 MCG
`0.5 mg
`10 ML
`5 MCG
`50 MCG
`10 MG
`12.5 MG
`40 MG
`125 MG
`1 MG
`1 GM
`0.1 MG
`10 UNITS
`1 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`50 MG
`0.9 MG
`10 MG
`1 MG
`1 MG
`200 MG
`80 MG
`1 MG
`1 MG
`1 MG
`10 MG
`1 MG
`3.75 MG
`1 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
`
`59.190
`9.758
`24.346
`74.301
`4.732
`36.366
`10.532
`0.073
`78.428
`10.181
`10.087
`115.667
`47.063
`111.935
`2.085
`4.171
`5.636
`87.154
`33.323
`0.776
`40.857
`1.590
`5.138
`129.255
`3.010
`9.014
`0.051
`1.543
`34.616
`1740.225
`315.880
`1.378
`135.673
`36.812
`3.492
`5.401
`62.806
`3.849
`1.329
`18.204
`385.610
`184.359
`12.033
`6.051
`2.771
`20.297
`346.147
`11.227
`7.834
`2.528
`7.819
`1.835
`3.806
`1.182
`
`Updated July 2021
`
`Added October 2020
`
`Exhibit 2241
`Page 07 of 13
`
`

`

`J3471
`J3473
`J3475
`J3480
`J3485
`J3486
`J3489
`J7030
`J7040
`J7042
`J7050
`J7060
`J7070
`J7120
`J7170
`J7175
`J7177
`J7178
`J7179
`J7180
`J7181
`J7182
`J7183
`J7185
`J7186
`J7187
`J7188
`J7189
`J7190
`J7192
`J7193
`J7194
`J7195
`J7197
`J7198
`J7200
`J7201
`J7202
`J7203
`J7204
`J7205
`J7207
`J7208
`J7209
`J7210
`J7211
`J7308
`J7311
`J7312
`J7313
`J7314
`J7316
`J7321
`J7323
`
`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
`Inj., emicizumab-kxwh 0.5 mg
`Inj, factor x, (human), 1iu
`Inj., fibryga, 1 mg
`Inj human fibrinogen con nos
`Vonvendi inj 1 iu vwf:rco
`Factor xiii anti-hem factor
`Factor xiii recomb a-subunit
`Factor viii recomb novoeight
`Wilate injection
`Xyntha inj
`Antihemophilic viii/vwf comp
`Humate-p, inj
`Factor viii recomb obizur
`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
`Factor ix idelvion inj
`Factor ix recomb gly rebinyn
`Inj recombin esperoct per iu
`Factor viii fc fusion recomb
`Factor viii pegylated recomb
`Inj. jivi 1 iu
`Factor viii nuwiq recomb 1iu
`Inj, afstyla, 1 i.u.
`Inj, kovaltry, 1 i.u.
`Aminolevulinic acid hcl top
`Inj., retisert, 0.01 mg
`Dexamethasone intra implant
`Inj., iluvien, 0.01 mg
`Inj., yutiq, 0.01 mg
`Inj, ocriplasmin, 0.125 mg
`Hyalgan or supartz inj dose
`Euflexxa inj per dose
`
`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
`0.5 MG
`1 IU
`1 MG
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 I.U. VWF:RCO
`1 IU
`PER FACTOR VIII IU
`1 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
`1 MG
`1 i.u.
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`354 MG
`0.01 MG
`0.1 MG
`0.01 MG
`0.01 MG
`0.125 MG
`per dose
`per dose
`
`0.457
`0.359
`0.423
`0.154
`1.512
`23.873
`9.709
`2.538
`1.269
`1.083
`0.634
`2.041
`4.019
`2.340
`47.467
`7.879
`1.074
`1.243
`1.783
`8.773
`15.526
`1.266
`1.023
`1.306
`1.136
`1.207
`3.186
`2.250
`1.015
`1.378
`1.164
`1.491
`1.534
`3.504
`2.051
`1.456
`3.252
`4.438
`4.009
`2.286
`2.167
`1.874
`2.020
`1.355
`1.338
`1.219
`394.752
`340.622
`199.756
`490.873
`491.133
`1046.927
`79.812
`140.312
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`1
`1
`1
`1
`1
`
`1
`1
`1
`1
`1
`1
`
`updated April 2021
`
`Added October 2020
`
`Exhibit 2241
`Page 08 of 13
`
`

`

`J7324
`J7325
`J7327
`J7331
`J7336
`J7340
`J7342
`J7345
`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
`J7677
`J7682
`J7686
`J8501
`J8520
`J8521
`J8530
`J8540
`J8560
`J8610
`J8655
`J8670
`J8700
`J8705
`J9000
`J9017
`
`Orthovisc inj per dose
`Synvisc or synvisc-one
`Monovisc inj per dose
`Synojoynt, inj., 1 mg
`Capsaicin 8% patch
`Carbidopa levodopa ent 100ml
`Ciprofloxacin otic susp 6 mg
`Aminolevulinic acid, 10% gel
`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
`Revefenacin inh non-com 1mcg
`Tobramycin non-comp unit
`Treprostinil, non-comp unit
`Oral aprepitant
`Capecitabine, oral, 150 mg
`Capecitabine, oral, 500 mg
`Cyclophosphamide oral 25 mg
`Oral dexamethasone
`Etoposide oral 50 mg
`Methotrexate oral 2.5 mg
`Oral netupitant, palonosetro
`Rolapitant, oral, 1mg
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Arsenic trioxide injection
`
`PER DOSE
`1 MG
`PER DOSE
`1 MG
`1 SQ CM
`100 ML
`6 MG
`10 MG
`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
`1 MCG
`300 MG
` 1.74 MG
`5 MG
`150 MG
`500 MG
`25 MG
`0.25 MG
`50 MG
`2.5 MG
`0.5 MG
`1 MG
`5 MG
`0.25 mg
`10 MG
`1 MG
`
`128.409
`10.218
`694.582
`4.394
`3.250
`213.095
`29.968
`1.525
`1.160
`1.785
`1.383
`2257.665
`0.751
`0.477
`0.248
`0.123
`817.122
`0.013
`0.644
`61.747
`0.414
`1.904
`6.383
`211.974
`8.028
`11.169
`11.647
`5.923
`0.337
`0.377
`0.041
`0.060
`0.124
`1.589
`2.705
`47.787
`0.197
`0.764
`0.197
`32.459
`642.992
`4.855
`0.668
`2.408
`2.017
`0.104
`75.493
`0.150
`270.102
`2.266
`0.622
`103.828
`2.703
`22.063
`
`Added October 2020
`
`Updated October 2021
`
`Updated October 2021
`
`updated April 2021
`
`Exhibit 2241
`Page 09 of 13
`
`

`

`J9019
`J9022
`J9023
`J9025
`J9027
`J9030
`J9032
`J9033
`J9034
`J9035
`J9036
`J9039
`J9040
`J9041
`J9042
`J9043
`J9044
`J9045
`J9047
`J9050
`J9055
`J9060
`J9065
`J9070
`J9100
`J9119
`J9120
`J9130
`J9145
`J9150
`J9153
`J9155
`J9171
`J9173
`J9176
`J9177
`J9178
`J9179
`J9181
`J9185
`J9190
`J9200
`J9201
`J9202
`J9203
`J9204
`J9205
`J9206
`J9207
`J9208
`J9209
`J9210
`J9211
`J9214
`
`Erwinaze injection
`Inj, atezolizumab,10 mg
`Injection, avelumab, 10 mg
`Azacitidine injection
`Clofarabine injection
`Bcg live intravesical 1mg
`Injection, belinostat, 10mg
`Inj., treanda 1 mg
`Inj., bendeka 1 mg
`Bevacizumab injection
`Inj. belrapzo/bendamustine
`Injection, blinatumomab
`Bleomycin sulfate injection
`Inj., velcade 0.1 mg
`Brentuximab vedotin inj
`Cabazitaxel injection
`Inj, bortezomib, nos, 0.1 mg
`Carboplatin injection
`Injection, carfilzomib, 1 mg
`Carmustine injection
`Cetuximab injection
`Cisplatin 10 mg injection
`Inj cladribine per 1 mg
`Cyclophosphamide 100 mg inj
`Cytarabine hcl 100 mg inj
`Inj., cemiplimab-rwlc, 1 mg
`Dactinomycin injection
`Dacarbazine 100 mg inj
`Injection, daratumumab 10 mg
`Daunorubicin injection
`Inj daunorubicin, cytarabine
`Degarelix injection
`Docetaxel injection
`Inj., durvalumab, 10 mg
`Injection, elotuzumab, 1mg
`Inj enfort vedo-ejfv 0.25mg
`Inj, epirubicin hcl, 2 mg
`Eribulin mesylate injection
`Etoposide injection
`Fludarabine phosphate inj
`Fluorouracil injection
`Floxuridine injection
`In gemcitabine hcl nos 200mg
`Goserelin acetate implant
`Gemtuzumab ozogamicin 0.1 mg
`Inj mogamulizumab-kpkc, 1 mg
`Inj irinotecan liposome 1 mg
`Irinotecan injection
`Ixabepilone injection
`Ifosfamide injection
`Mesna injection
`Inj., emapalumab-lzsg, 1 mg
`Idarubicin hcl injection
`Interferon alfa-2b inj
`
`1,000 IU
`10 MG
`10 MG
`1 MG
`1 MG
`1 MG
`10 MG
`1 MG
`1 MG
`10 MG
`1 MG
`1 MCG
`15 UNITS
`0.1 MG
`1 MG
`1 MG
`0.1 MG
`50 MG
`1 MG
`100 MG
`10 MG
`10 MG
`1 MG
`100 MG
`100 MG
`1 MG
`0.5 MG
`100 MG
`10 MG
`10 MG
`1 MG/2.27 MG
`1 MG
`1 MG
`10 MG
`1 MG
`0.25 MG
`2 MG
`0.1 MG
`10 MG
`50 MG
`500 MG
`500 MG
`200 MG
`3.6 MG
`0.1 MG
`1 MG
`1 MG
`20 MG
`1 MG
`1 GM
`200 MG
`1 MG
`5 MG
`1 MIL UNITS
`
`427.269
`78.279
`84.700
`0.801
`52.637
`2.793
`42.794
`24.693
`20.273
`76.361
`21.612
`118.586
`26.923
`44.973
`175.282
`181.509
`22.036
`2.758
`39.198
`2016.270
`64.409
`1.713
`19.573
`29.672
`0.680
`27.401
`1044.534
`4.459
`56.286
`43.838
`197.794
`3.842
`0.851
`76.023
`6.671
`27.958
`1.530
`117.663
`0.768
`66.011
`1.528
`46.439
`3.957
`503.586
`205.380
`203.883
`54.331
`2.536
`101.189
`26.312
`2.127
`441.593
`37.664
`34.346
`
`Updated January 2021
`
`AMP-based payment limit
`
`Added October 2020
`
`Exhibit 2241
`Page 10 of 13
`
`

`

`J9217
`J9218
`J9225
`J9226
`J9227
`J9228
`J9229
`J9245
`J9250
`J9260
`J9261
`J9262
`J9263
`J9264
`J9266
`J9267
`J9268
`J9269
`J9271
`J9280
`J9285
`J9293
`J9295
`J9299
`J9301
`J9302
`J9303
`J9305
`J9306
`J9307
`J9308
`J9309
`J9311
`J9312
`J9313
`J9315
`J9320
`J9325
`J9328
`J9330
`J9340
`J9351
`J9352
`J9354
`J9355
`J9356
`J9357
`J9358
`J9360
`J9370
`J9371
`J9390
`J9395
`J9400
`
`Leuprolide acetate suspnsion
`Leuprolide acetate injeciton
`Vantas implant
`Supprelin la implant
`Inj. isatuximab-irfc 10 mg
`Ipilimumab injection
`Inj inotuzumab ozogam 0.1 mg
`Inj melpha hydroch nos 50 mg
`Methotrexate sodium inj
`Methotrexate sodium inj
`Nelarabine injection
`Inj, omacetaxine mep, 0.01mg
`Oxaliplatin
`Paclitaxel protein bound
`Pegaspargase injection
`Paclitaxel injection
`Pentostatin injection
`Inj. tagraxofusp-erzs 10 mcg
`Inj pembrolizumab
`Mitomycin injection
`Inj, olaratumab, 10 mg
`Mitoxantrone hydrochl / 5 mg
`Injection, necitumumab, 1 mg
`Injection, nivolumab
`Obinutuzumab inj
`Ofatumumab injection
`Panitumumab injection
`Inj. pemetrexed nos 10mg
`Injection, pertuzumab, 1 mg
`Pralatrexate injection
`Injection, ramucirumab
`Inj, polatuzumab vedotin 1mg
`Inj rituximab, hyaluronidase
`Inj., rituximab, 10 mg
`Inj., lumoxiti, 0.01 mg
`Romidepsin injection
`Streptozocin injection
`Inj talimogene laherparepvec
`Temozolomide injection
`Temsirolimus injection
`Thiotepa injection
`Topotecan injection
`Injection trabectedin 0.1mg
`Inj, ado-trastuzumab emt 1mg
`Inj trastuzumab excl biosimi
`Inj. herceptin hylecta, 10mg
`Valrubicin injection
`Inj fam-trastu deru-nxki 1mg
`Vinblastine sulfate inj
`Vincristine sulfate 1 mg inj
`Inj, vincristine sul lip 1mg
`Vinorelbine tartrate inj
`Injection, fulvestrant
`Inj, ziv-aflibercept, 1mg
`
`7.5 MG
`1 MG
`50 MG
`50 MG
`10 MG
`1 MG
`0.1 MG
`50 MG
`5 MG
`50 MG
`50 MG
`0.01 MG
`0.5 MG
`1 MG
`1 EA
`1 MG
`10 MG
`10 MCG
`1 MG
`5 MG
`10 MG
`5 MG
`1 MG
`1 MG
`10 MG
`10 MG
`10 MG
`10 MG
`1 MG
`1 MG
`5 MG
`1 MG
`10 mg
`10 MG
`0.01 MG
`1 MG
`1 GM
`1 million PFU
`1 MG
`1 MG
`15 MG
`0.1 MG
`0.1 MG
`1 MG
`10 MG
`10 MG
`200 MG
`1 MG
`1 MG
`1 MG
`1 MG
`10 MG
`25 MG
`1 MG
`
`224.452
`23.091
`4558.133
`40237.001
`66.670
`157.382
`2341.499
`260.376
`0.233
`2.325
`152.151
`2.976
`0.117
`13.298
`19717.763
`0.155
`2060.277
`270.585
`50.846
`49.879
`52.067
`28.688
`5.731
`28.559
`63.736
`61.942
`123.553
`71.954
`12.945
`311.224
`60.709
`110.717
`41.140
`92.556
`22.460
`336.542
`349.537
`53.923
`10.377
`44.989
`475.392
`1.275
`318.927
`32.789
`99.675
`75.084
`1403.170
`24.142
`3.982
`5.339
`3320.169
`9.463
`52.875
`8.073
`
`Added October 2020
`
`Added October 2020
`
`Updated January 2021
`
`Added October 2020
`
`updated April 2021
`
`Exhibit 2241
`Page 11 of 13
`
`

`

`P9041
`P9045
`P9046
`P9047
`Q0138
`Q0139
`Q0162
`Q0164
`Q0166
`Q0167
`Q2043
`Q2050
`Q3027
`Q4074
`Q4081
`Q4101
`Q4102
`Q4106
`Q4110
`Q4111
`Q4121
`Q4132
`Q4133
`Q4137
`Q4145
`Q4151
`Q4154
`Q4160
`Q4186
`Q4195
`Q4196
`Q5101
`Q5103
`Q5104
`Q5105
`Q5106
`Q5107
`Q5108
`Q5110
`Q5111
`Q5112
`Q5113
`Q5114
`Q5115
`Q5116
`Q5117
`Q5118
`Q5119
`Q5120
`Q5121
`Q9950
`Q9956
`Q9957
`Q9958
`
`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
`Prochlorperazine maleate 5mg
`Granisetron hcl 1 mg oral
`Dronabinol 2.5mg oral
`Sipuleucel-t auto cd54+
`Doxorubicin inj 10mg
`Inj beta interferon im 1 mcg
`Iloprost non-comp unit dose
`Epoetin alfa, 100 units esrd
`Apligraf
`Oasis wound matrix
`Dermagraft
`Primatrix
`Gammagraft
`Theraskin
`Grafix core, grafixpl core
`Grafix stravix prime pl sqcm
`Amnioexcel biodexcel 1sq cm
`Epifix, inj, 1mg
`Amnioband, guardian 1 sq cm
`Biovance 1 square cm
`Nushield 1 square cm
`Epifix 1 sq cm
`Puraply 1 sq cm
`Puraply am 1 sq cm
`Injection, zarxio
`Injection, inflectra
`Injection, renflexis
`Inj retacrit esrd on dialysi
`Inj retacrit non-esrd use
`Inj mvasi 10 mg
`Injection, fulphila
`Nivestym
`Injection, udenyca 0.5 mg
`Inj ontruzant 10 mg
`Inj herzuma 10 mg
`Inj ogivri 10 mg
`Inj truxima 10 mg
`Inj., trazimera, 10 mg
`Inj., kanjinti, 10 mg
`Inj., zirabev, 10 mg
`Inj ruxience, 10 mg
`Inj pegfilgrastim-bmez 0.5mg
`Inj. avsola, 10 mg
`Inj sulf hexa lipid microsph
`Inj octafluoropropane mic,ml
`Inj perflutren lip micros,ml
`Hocm <=149 mg/ml iodine, 1ml
`
`
`
`50 ML
`250 ML
`20 ML
`50 ML
`1 MG
`1 MG
`1 MG
`5 MG
`1 MG
`2.5 MG
`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 MG
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 MCG
`10 MG
`10 MG
`100 UNITS
`1000 UNITS
`10 MG
`0.5 MG
`1 MCG
`0.5 MG
`10 MG
`10 MG
`10 MG
`10 MG
`10 MG
`10 MG
`10 MG
`10 MG
`0.5 MG
`10 MG
`1 ML
`1 ML
`1 ML
`1 ML
`
`10.490
`52.450
`20.980
`52.450
`0.983
`0.983
`0.012
`0.256
`1.330
`0.677
`49671.772
`315.731
`54.322
`140.403
`0.911
`30.458
`10.214
`32.007
`46.405
`6.936
`39.149
`114.628
`131.423
`85.361
`18.327
`124.346
`116.584
`100.110
`155.994
`105.940
`111.585
`0.468
`43.724
`44.547
`0.861
`8.612
`60.939
`269.041
`0.621
`286.674
`92.296
`91.523
`76.407
`68.799
`83.104
`78.723
`62.235
`70.900
`305.552
`51.500
`18.329
`31.751
`47.627
`0.068
`
`95
`95
`95
`95
`
`10.490
`52.450
`20.980
`52.450
`
`AMP-based payment limit
`
`updated April 2021
`
`Updated January 2021
`
`Added October 2020
`
`Exhibit 2241
`Page 12 of 13
`
`

`

`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`Q9991
`Q9992
`
`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
`Buprenorph xr 100 mg or less
`Buprenorphine xr over 100 mg
`
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`ess than or equal to 100 M
`Greater than 100 MG
`
`0.200
`0.246
`0.182
`0.718
`0.336
`0.104
`1743.482
`1743.482
`
`Exhibit 2241
`Page 13 of 13
`
`