Denosumab · Hematology-Oncology
Prolia (J0897) carries a median commercial contracted rate of 98.0 on the Medicare ASP=100 index — 4.6% below the 102.7 typical-acquisition benchmark and 6.0% below the 104.3 Medicare payment line. 59 insurers report contracted rates across 52 states (1,063 priced cells), covering $1.98B in modeled Part B spend. It ranks #9 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 75.2 out of 100.
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), 85.8 (NADAC-measured acquisition, see below).
All 52 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 Nebraska | 120.0 | +16.8% | 34 | 7 |
| BlueCross BlueShield of South Carolina | 118.0 | +14.9% | 55 | 6 |
| BlueCross BlueShield of New Mexico | 115.1 | +12.1% | 185 | 3 |
| Regence Idaho | 112.1 | +9.2% | 45 | 6 |
| Regence Utah | 109.4 | +6.5% | 50 | 5 |
| BlueCross BlueShield of Arkansas | 106.2 | +3.4% | 48 | 21 |
| BCBS North Dakota | 106.2 | +3.4% | 139 | 3 |
| Blue Cross of Idaho | 105.9 | +3.1% | 48 | 6 |
| BlueCross BlueShield of Kansas | 105.0 | +2.2% | 60 | 5 |
| BlueCross BlueShield of Wyoming | 104.7 | +1.9% | 44 | 7 |
| Aetna | 102.8 | +0.1% | 708 | 51 |
| Premera Blue Cross | 102.6 | −0.1% | 102 | 9 |
| Anthem Massachusetts | 101.7 | −1.0% | 64 | 25 |
| BlueCross BlueShield of Louisiana | 101.6 | −1.1% | 54 | 7 |
| Blue Cross NC | 101.6 | −1.1% | 187 | 52 |
| Capital Blue Cross | 101.6 | −1.1% | 92 | 35 |
| HMSA (BCBS Hawaii) | 101.3 | −1.4% | 80 | 3 |
| Blue Shield of California | 100.5 | −2.1% | 118 | 4 |
| Anthem Wisconsin | 98.0 | −4.6% | 139 | 5 |
| Anthem Virginia | 98.0 | −4.6% | 72 | 20 |
| UnitedHealthcare | 98.0 | −4.6% | 1,068 | 52 |
| Harvard Pilgrim Health Care | 98.0 | −4.6% | 229 | 10 |
| Anthem Kentucky | 98.0 | −4.6% | 71 | 10 |
| Regence BlueCross BlueShield | 98.0 | −4.6% | 56 | 14 |
| BlueCross BlueShield of Massachusetts | 98.0 | −4.6% | 60 | 7 |
| BlueCross BlueShield of Oklahoma | 98.0 | −4.6% | 79 | 2 |
| Anthem Missouri | 98.0 | −4.6% | 42 | 10 |
| Regence Washington | 97.9 | −4.7% | 75 | 5 |
| Cigna | 97.9 | −4.7% | 649 | 51 |
| BlueCross BlueShield of Alabama | 97.9 | −4.7% | 91 | 6 |
| Anthem Maine | 97.9 | −4.7% | 65 | 5 |
| Anthem New York | 97.9 | −4.7% | 72 | 15 |
| Regence Oregon | 97.9 | −4.7% | 58 | 7 |
| Anthem Nevada | 97.9 | −4.7% | 194 | 4 |
| Florida Blue | 97.9 | −4.7% | 32 | 5 |
| Anthem Georgia | 97.9 | −4.7% | 64 | 16 |
| CareFirst BlueCross BlueShield | 97.9 | −4.7% | 59 | 18 |
| Anthem Connecticut | 97.9 | −4.7% | 66 | 5 |
| Centene | 97.9 | −4.7% | 614 | 32 |
| Kaiser Permanente | 97.9 | −4.7% | 312 | 8 |
| Anthem New Hampshire | 97.9 | −4.7% | 49 | 7 |
| Anthem Ohio | 97.9 | −4.7% | 78 | 13 |
| BlueCross BlueShield of Rhode Island | 97.9 | −4.7% | 291 | 3 |
| Anthem Indiana | 97.9 | −4.7% | 136 | 25 |
| Anthem California | 97.7 | −4.9% | 64 | 4 |
| Wellmark BCBS (Iowa/South Dakota) | 97.6 | −5.0% | 78 | 10 |
| BlueCross BlueShield of Tennessee | 97.6 | −5.0% | 61 | 10 |
| BlueCross BlueShield of Minnesota | 97.6 | −5.0% | 68 | 7 |
| BlueCross BlueShield of Texas | 92.9 | −9.5% | 41 | 17 |
| Horizon BCBS of New Jersey | 92.4 | −10.0% | 42 | 6 |
| BlueCross BlueShield of Michigan | 90.7 | −11.7% | 63 | 7 |
| BlueCross BlueShield of Arizona | 82.2 | −20.0% | 38 | 19 |
Medicare's payment limit for Prolia moved +39.2% 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.
| Year | Part B spend | Dosage units (M) |
|---|---|---|
| 2019 | $1.60B | 91.8 |
| 2020 | $1.63B | 88.9 |
| 2021 | $1.78B | 92.8 |
| 2022 | $2.00B | 93.8 |
| 2023 | $2.19B | 94.7 |
| 2024 | $2.43B | — |
| 2025 | $1.98B | — |
NADAC-measured acquisition cost for Prolia runs $23.87/unit as of 2026-01-07 — an acquisition index of 85.8 (ASP = 100).
At the median contracted index of 98.0, that implies a modeled gross margin of +12.2 points per ASP-unit — roughly +$3.46/unit at the latest ASP of $28.40.
Modeled from NADAC acquisition, medium confidence — your invoice price governs.
| Highest-paying states | Index | Insurers |
|---|---|---|
| Alaska (AK) | 123.6 | 7 |
| Idaho (ID) | 110.7 | 12 |
| Nebraska (NE) | 109.7 | 9 |
| Utah (UT) | 105.9 | 12 |
| Kansas (KS) | 105.6 | 11 |
| Lowest-paying states | Index | Insurers |
|---|---|---|
| Minnesota (MN) | 97.9 | 13 |
| Georgia (GA) | 97.9 | 24 |
| Pennsylvania (PA) | 97.9 | 18 |
| Mississippi (MS) | 97.9 | 12 |
| Iowa (IA) | 97.9 | 10 |
| Prior authorization required | 83% of policies |
| Site-of-care steering | 26% of policies |
| Pharmacy (white-bag) channel multiple | 0.990× |
| Drug class | RANKL inhibitor |
At the median contracted rate, this code models a −$4,541 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 1,063 priced contract cells across 59 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.
See also: Ocrevus · Xolair · Enhertu · report home · methodology