Cimzia (J0717): what insurers contract to pay

Certolizumab Pegol · Rheumatology

CareCost Research · Reviewed by Erin Rose

Cimzia (J0717) carries a median commercial contracted rate of 113.5 on the Medicare ASP=100 index — 10.5% above the 102.7 typical-acquisition benchmark and 8.8% above the 104.3 Medicare payment line. 57 insurers report contracted rates across 52 states (1,020 priced cells), covering $274M in modeled Part B spend.

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 49 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	432.9	+321.5%	55	6
BlueCross BlueShield of Wyoming	384.1	+274.0%	44	7
Blue Cross of Idaho	311.0	+202.8%	58	6
Blue Cross NC	237.5	+131.3%	187	52
Premera Blue Cross	196.6	+91.4%	102	9
HMSA (BCBS Hawaii)	164.1	+59.8%	66	4
Kaiser Permanente	148.7	+44.8%	312	8
Regence Idaho	128.6	+25.2%	45	6
BlueCross BlueShield of Texas	128.3	+24.9%	42	10
BlueCross BlueShield of Nebraska	126.9	+23.6%	34	7
Regence Utah	125.6	+22.3%	50	5
BlueCross BlueShield of Kansas	122.8	+19.6%	60	5
Blue Shield of California	122.2	+19.0%	112	4
BlueCross BlueShield of Arkansas	122.0	+18.8%	48	21
BCBS North Dakota	122.0	+18.8%	139	3
BlueCross BlueShield of Louisiana	121.4	+18.2%	54	7
Capital Blue Cross	116.4	+13.3%	92	35
Aetna	116.1	+13.0%	794	51
Horizon BCBS of New Jersey	115.6	+12.6%	41	6
Anthem Massachusetts	114.1	+11.1%	64	25
BlueCross BlueShield of Tennessee	113.5	+10.5%	61	10
Centene	113.5	+10.5%	125	20
Wellmark BCBS (Iowa/South Dakota)	113.5	+10.5%	78	10
Anthem California	113.0	+10.0%	64	4
Regence Oregon	112.4	+9.4%	64	7
BlueCross BlueShield of Alabama	112.4	+9.4%	91	6
Anthem Georgia	112.4	+9.4%	63	16
BlueCross BlueShield of Rhode Island	112.4	+9.4%	291	3
Anthem New Hampshire	112.4	+9.4%	42	7
CareFirst BlueCross BlueShield	112.4	+9.4%	59	18
Florida Blue	112.4	+9.4%	32	5
Regence Washington	112.4	+9.4%	75	5
Anthem Nevada	112.4	+9.4%	194	4
Cigna	112.4	+9.4%	608	52
Anthem Ohio	112.4	+9.4%	78	13
Anthem New York	112.4	+9.4%	72	15
UnitedHealthcare	112.4	+9.4%	1,080	51
Anthem Connecticut	112.4	+9.4%	66	5
Anthem Indiana	112.4	+9.4%	136	25
Anthem Maine	112.4	+9.4%	65	5
Anthem Virginia	111.2	+8.3%	72	20
Anthem Missouri	111.2	+8.3%	46	8
Harvard Pilgrim Health Care	110.0	+7.1%	229	10
Regence BlueCross BlueShield	110.0	+7.1%	58	14
Anthem Wisconsin	110.0	+7.1%	154	5
Anthem Kentucky	110.0	+7.1%	85	9
BlueCross BlueShield of Michigan	108.3	+5.5%	63	7
BlueCross BlueShield of Minnesota	96.5	−6.0%	68	7
BlueCross BlueShield of Arizona	93.4	−9.1%	38	19

The price history

Medicare's payment limit for Cimzia moved -39.6% between Q1 2022 and Q2 2026. Because contracted rates are set as a multiple of ASP, a falling denominator drags every contracted rate down with it, typically with a two-quarter lag as CMS updates the published benchmark.

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	$439M	57.1
2020	$509M	64.0
2021	$500M	70.8
2022	$432M	76.5
2023	$401M	81.7
2024	$398M	—
2025	$274M	—

Where it pays most and least

Highest-paying states	Index	Insurers
Alaska (AK)	186.0	7
Hawaii (HI)	135.9	7
Washington (WA)	128.6	17
Nebraska (NE)	126.9	8
Wyoming (WY)	126.9	5

Lowest-paying states	Index	Insurers
Indiana (IN)	112.4	15
Minnesota (MN)	112.4	13
New Hampshire (NH)	112.4	10
Florida (FL)	112.4	34
Vermont (VT)	112.4	8

Getting paid for it

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 +$10,516 cushion 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 1,020 priced contract cells across 57 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.

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