Pegloticase · Gastroenterology
Krystexxa (J2507) carries a median commercial contracted rate of 97.3 on the Medicare ASP=100 index — 5.3% below the 102.7 typical-acquisition benchmark and 6.7% below the 104.3 Medicare payment line. 57 insurers report contracted rates across 52 states (1,003 priced cells), covering $241M in modeled Part B spend. It ranks #15 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 70.1 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).
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 | 121.3 | +18.1% | 56 | 6 |
| Regence Idaho | 109.8 | +6.9% | 45 | 6 |
| BlueCross BlueShield of Nebraska | 108.6 | +5.7% | 34 | 7 |
| Regence Utah | 107.2 | +4.4% | 50 | 5 |
| Blue Shield of California | 104.6 | +1.9% | 101 | 4 |
| BCBS North Dakota | 104.1 | +1.4% | 139 | 3 |
| BlueCross BlueShield of Arkansas | 104.1 | +1.4% | 48 | 21 |
| BlueCross BlueShield of Wyoming | 103.1 | +0.4% | 44 | 7 |
| Anthem Massachusetts | 101.0 | −1.7% | 64 | 25 |
| Blue Cross of Idaho | 99.8 | −2.8% | 58 | 6 |
| Aetna | 99.8 | −2.8% | 788 | 51 |
| Capital Blue Cross | 99.5 | −3.1% | 92 | 35 |
| BlueCross BlueShield of Kansas | 99.2 | −3.4% | 60 | 5 |
| Blue Cross NC | 98.6 | −4.0% | 195 | 52 |
| Premera Blue Cross | 97.8 | −4.8% | 103 | 9 |
| Regence BlueCross BlueShield | 97.3 | −5.3% | 56 | 14 |
| Anthem Missouri | 97.3 | −5.3% | 42 | 9 |
| Anthem Kentucky | 97.3 | −5.3% | 85 | 9 |
| Harvard Pilgrim Health Care | 97.3 | −5.3% | 229 | 10 |
| Anthem Wisconsin | 97.3 | −5.3% | 96 | 6 |
| Anthem Virginia | 96.6 | −5.9% | 72 | 20 |
| Anthem Indiana | 95.9 | −6.6% | 136 | 25 |
| Anthem Maine | 95.9 | −6.6% | 65 | 5 |
| Cigna | 95.9 | −6.6% | 649 | 51 |
| Anthem Georgia | 95.9 | −6.6% | 64 | 16 |
| Anthem New York | 95.9 | −6.6% | 72 | 15 |
| Anthem Nevada | 95.9 | −6.6% | 194 | 4 |
| Regence Oregon | 95.9 | −6.6% | 58 | 7 |
| Anthem Ohio | 95.9 | −6.6% | 78 | 13 |
| Kaiser Permanente | 95.9 | −6.6% | 312 | 8 |
| Anthem New Hampshire | 95.9 | −6.6% | 49 | 7 |
| BlueCross BlueShield of Rhode Island | 95.9 | −6.6% | 291 | 3 |
| BlueCross BlueShield of Alabama | 95.9 | −6.6% | 91 | 6 |
| Anthem Connecticut | 95.9 | −6.6% | 66 | 5 |
| Florida Blue | 95.9 | −6.6% | 32 | 5 |
| Regence Washington | 95.9 | −6.6% | 75 | 5 |
| CareFirst BlueCross BlueShield | 95.9 | −6.6% | 58 | 19 |
| UnitedHealthcare | 95.9 | −6.6% | 1,080 | 51 |
| BlueCross BlueShield of Louisiana | 95.6 | −6.9% | 54 | 7 |
| HMSA (BCBS Hawaii) | 95.6 | −6.9% | 66 | 4 |
| Centene | 94.5 | −8.0% | 518 | 6 |
| Anthem California | 94.5 | −8.0% | 64 | 4 |
| BlueCross BlueShield of Texas | 94.0 | −8.5% | 47 | 10 |
| Wellmark BCBS (Iowa/South Dakota) | 93.2 | −9.3% | 78 | 10 |
| BlueCross BlueShield of Minnesota | 93.2 | −9.3% | 68 | 7 |
| BlueCross BlueShield of Tennessee | 93.2 | −9.3% | 61 | 10 |
| BlueCross BlueShield of Michigan | 92.8 | −9.6% | 63 | 7 |
| Horizon BCBS of New Jersey | 86.8 | −15.5% | 42 | 6 |
| BlueCross BlueShield of Arizona | 80.6 | −21.5% | 38 | 19 |
Medicare's payment limit for Krystexxa moved +28.8% 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 | $113M | 0.0 |
| 2020 | $142M | 0.1 |
| 2021 | $160M | 0.1 |
| 2022 | $201M | 0.1 |
| 2023 | $247M | 0.1 |
| 2024 | $283M | — |
| 2025 | $241M | — |
| Highest-paying states | Index | Insurers |
|---|---|---|
| Nebraska (NE) | 108.6 | 8 |
| Alaska (AK) | 106.6 | 7 |
| Idaho (ID) | 105.2 | 12 |
| Arkansas (AR) | 104.1 | 9 |
| Utah (UT) | 103.1 | 12 |
| Lowest-paying states | Index | Insurers |
|---|---|---|
| Maryland (MD) | 95.9 | 13 |
| Mississippi (MS) | 95.9 | 11 |
| Louisiana (LA) | 95.9 | 9 |
| Georgia (GA) | 95.9 | 23 |
| Nevada (NV) | 95.9 | 11 |
| Prior authorization required | 77% of policies |
| Site-of-care steering | 41% of policies |
| Pharmacy (white-bag) channel multiple | 0.980× |
| Drug class | PEGylated recombinant uricase |
At the median contracted rate, this code models a −$5,226 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 1,003 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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