Orencia (J0129): what insurers contract to pay

Abatacept · Rheumatology

CareCost Research · Reviewed by Erin Rose

Orencia (J0129) carries a median commercial contracted rate of 97.6 on the Medicare ASP=100 index — 5.0% below the 102.7 typical-acquisition benchmark and 6.4% below the 104.3 Medicare payment line. 58 insurers report contracted rates across 52 states (1,056 priced cells), covering $718M in modeled Part B spend. It ranks #3 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 82.1 out of 100.

Contracted rate range across insurers

Shaded band: 10th–90th percentile across insurers. Darker band: 25th–75th percentile. Solid tick: median. Dashed lines: 100 (Medicare ASP), 102.7 (typical acquisition cost), 104.3 (Medicare payment after sequestration).

What each insurer contracts to pay

All 50 insurers with published rates for this code, ranked highest to lowest. Index is a multiple of Medicare ASP (ASP=100).

Insurer	Index	vs. acquisition	Practices	States
BlueCross BlueShield of South Carolina	146.4	+42.6%	56	6
BlueCross BlueShield of Wyoming	142.7	+38.9%	44	7
HMSA (BCBS Hawaii)	142.5	+38.8%	69	4
BlueCross BlueShield of Michigan	121.2	+18.0%	63	7
Premera Blue Cross	114.4	+11.4%	102	9
Blue Cross NC	112.5	+9.5%	187	52
Regence Idaho	111.8	+8.9%	45	6
BlueCross BlueShield of Nebraska	110.5	+7.6%	34	7
Regence Utah	109.1	+6.2%	50	5
Blue Shield of California	108.2	+5.4%	118	4
Blue Cross of Idaho	107.4	+4.6%	58	6
BlueCross BlueShield of Arkansas	105.9	+3.1%	48	21
BCBS North Dakota	105.9	+3.1%	139	3
BlueCross BlueShield of Louisiana	102.9	+0.2%	54	7
Aetna	102.5	−0.2%	742	51
Kaiser Permanente	101.7	−1.0%	312	8
Capital Blue Cross	101.3	−1.4%	92	35
Anthem Massachusetts	101.2	−1.5%	64	25
BlueCross BlueShield of Kansas	100.9	−1.8%	60	5
BlueCross BlueShield of Texas	100.4	−2.2%	46	22
Anthem Connecticut	97.6	−5.0%	66	5
Anthem Indiana	97.6	−5.0%	136	25
Anthem Maine	97.6	−5.0%	65	5
CareFirst BlueCross BlueShield	97.6	−5.0%	58	19
Anthem Nevada	97.6	−5.0%	194	4
Anthem New York	97.6	−5.0%	72	15
Anthem Ohio	97.6	−5.0%	78	13
Anthem Georgia	97.6	−5.0%	64	16
Anthem New Hampshire	97.6	−5.0%	49	7
Regence Oregon	97.6	−5.0%	64	7
BlueCross BlueShield of Alabama	97.6	−5.0%	91	6
Anthem Virginia	97.6	−5.0%	72	20
Regence Washington	97.6	−5.0%	75	5
Florida Blue	97.6	−5.0%	32	5
UnitedHealthcare	97.6	−5.0%	1,080	51
Centene	97.6	−5.0%	150	26
Cigna	97.6	−5.0%	636	52
BlueCross BlueShield of Rhode Island	97.6	−5.0%	291	3
Anthem Wisconsin	97.5	−5.1%	92	6
BlueCross BlueShield of Massachusetts	97.5	−5.1%	52	5
Anthem Kentucky	97.5	−5.1%	85	9
Anthem Missouri	97.5	−5.1%	40	11
Regence BlueCross BlueShield	97.5	−5.1%	58	14
Harvard Pilgrim Health Care	97.5	−5.1%	229	10
Anthem California	96.9	−5.6%	64	4
BlueCross BlueShield of Minnesota	96.2	−6.3%	68	7
Wellmark BCBS (Iowa/South Dakota)	96.2	−6.3%	78	10
BlueCross BlueShield of Tennessee	96.2	−6.3%	61	10
Horizon BCBS of New Jersey	94.6	−7.9%	42	6
BlueCross BlueShield of Arizona	82.0	−20.2%	38	19

The price history

Medicare's payment limit for Orencia moved +0.4% between Q1 2022 and Q2 2026. Because contracted rates are set as a multiple of ASP, a rising denominator lifts every contracted rate tied to it.

Solid dots: finalized CMS ASP quarters. Hollow dots: preliminary. Values are the Medicare payment limit (ASP + 6%, pre-sequestration) per billing unit.

Part B utilization

Year	Part B spend	Dosage units (M)
2019	$920M	18.3
2020	$1.02B	19.1
2021	$989M	20.1
2022	$903M	20.9
2023	$903M	21.4
2024	$930M	—
2025	$718M	—

Where it pays most and least

Highest-paying states	Index	Insurers
Alaska (AK)	129.5	7
Hawaii (HI)	113.5	7
Idaho (ID)	110.4	12
Montana (MT)	108.0	6
Oregon (OR)	107.4	14

Lowest-paying states	Index	Insurers
Pennsylvania (PA)	97.6	18
New York (NY)	97.6	24
Delaware (DE)	97.6	8
West Virginia (WV)	97.6	11

Getting paid for it

Prior authorization required	90% of policies
Site-of-care steering	30% of policies
Pharmacy (white-bag) channel multiple	omitted — medium confidence
Drug class	T-cell costimulation modulator (CTLA-4 Ig)

Selected for Medicare drug price negotiation. The negotiated Maximum Fair Price (MFP) takes effect 2028-01-01; from that date CMS publishes only 106% of MFP as the benchmark for this drug, replacing ASP+6%. The figures on this page are the commercial baseline before that change.

What this means in dollars

At the median contracted rate, this code models a −$4,941 shortfall per $100,000 of acquisition-benchmark drug cost purchased — illustrative modeled margin exposure, not a claim about any single practice's actual reimbursement.

Based on 1,056 priced contract cells across 58 insurers and 52 states. These are insurers' contracted rates from published machine-readable files — not amounts actually paid on a claim, and not a guarantee of coverage or reimbursement. CareCost Estimate Infusion Reimbursement Index, Issue 01 (Q2 2026), v2.0. CC-BY 4.0. A drug-specific acquisition estimate exists in our warehouse but derives from ASP itself, so we do not print it — the flat 102.7 ODACS benchmark is the honest comparator here.