Pegcetacoplan · Ophthalmology
Syfovre (J2781) carries a median commercial contracted rate of 96.2 on the Medicare ASP=100 index — 6.3% below the 102.7 typical-acquisition benchmark and 7.8% below the 104.3 Medicare payment line. 51 insurers report contracted rates across 52 states (902 priced cells), covering $339M in modeled Part B spend. It ranks #5 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 79.5 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 41 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 | 126.0 | +22.7% | 55 | 6 |
| BlueCross BlueShield of Nebraska | 104.9 | +2.1% | 34 | 7 |
| Anthem Massachusetts | 103.0 | +0.3% | 64 | 25 |
| HMSA (BCBS Hawaii) | 103.0 | +0.3% | 69 | 4 |
| Kaiser Permanente | 102.5 | −0.2% | 312 | 8 |
| Blue Cross of Idaho | 101.9 | −0.8% | 67 | 6 |
| BlueCross BlueShield of Kansas | 101.0 | −1.7% | 60 | 5 |
| Premera Blue Cross | 100.7 | −1.9% | 103 | 9 |
| BCBS North Dakota | 100.6 | −2.0% | 139 | 3 |
| BlueCross BlueShield of Arkansas | 100.5 | −2.1% | 48 | 21 |
| BlueCross BlueShield of Louisiana | 100.0 | −2.6% | 54 | 7 |
| BlueCross BlueShield of Texas | 100.0 | −2.6% | 39 | 3 |
| Harvard Pilgrim Health Care | 99.2 | −3.4% | 229 | 10 |
| Anthem Wisconsin | 99.2 | −3.4% | 154 | 5 |
| Anthem Missouri | 99.2 | −3.4% | 42 | 8 |
| Anthem Kentucky | 99.2 | −3.4% | 92 | 8 |
| Blue Cross NC | 98.7 | −3.9% | 164 | 48 |
| Horizon BCBS of New Jersey | 96.7 | −5.8% | 44 | 6 |
| Capital Blue Cross | 96.2 | −6.3% | 92 | 35 |
| Aetna | 96.0 | −6.5% | 741 | 51 |
| Anthem Virginia | 96.0 | −6.5% | 63 | 19 |
| Blue Shield of California | 94.4 | −8.1% | 112 | 4 |
| BlueCross BlueShield of Tennessee | 93.4 | −9.1% | 61 | 10 |
| Wellmark BCBS (Iowa/South Dakota) | 93.4 | −9.1% | 78 | 10 |
| BlueCross BlueShield of Minnesota | 93.4 | −9.1% | 58 | 6 |
| Anthem California | 93.1 | −9.3% | 64 | 4 |
| BlueCross BlueShield of Alabama | 92.7 | −9.7% | 91 | 6 |
| CareFirst BlueCross BlueShield | 92.7 | −9.7% | 59 | 18 |
| Anthem New York | 92.7 | −9.7% | 72 | 15 |
| Anthem Nevada | 92.7 | −9.7% | 194 | 4 |
| UnitedHealthcare | 92.7 | −9.7% | 1,080 | 51 |
| Anthem Indiana | 92.7 | −9.7% | 141 | 24 |
| Cigna | 92.7 | −9.7% | 1,225 | 51 |
| Florida Blue | 92.7 | −9.7% | 32 | 5 |
| Anthem Connecticut | 92.7 | −9.7% | 66 | 5 |
| BlueCross BlueShield of Rhode Island | 92.7 | −9.7% | 291 | 3 |
| Anthem Georgia | 92.7 | −9.7% | 69 | 15 |
| Anthem Ohio | 92.7 | −9.7% | 78 | 13 |
| Anthem New Hampshire | 92.7 | −9.7% | 146 | 5 |
| Anthem Maine | 86.9 | −15.4% | 122 | 3 |
| BlueCross BlueShield of Arizona | 77.9 | −24.1% | 38 | 19 |
Medicare's payment limit for Syfovre moved -3.7% between Q4 2023 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.
| Year | Part B spend | Dosage units (M) |
|---|---|---|
| 2023 | $77M | 0.5 |
| 2024 | $404M | — |
| 2025 | $339M | — |
| Highest-paying states | Index | Insurers |
|---|---|---|
| Alaska (AK) | 118.8 | 6 |
| Nebraska (NE) | 103.0 | 8 |
| Hawaii (HI) | 102.5 | 7 |
| Kansas (KS) | 101.0 | 10 |
| Washington (WA) | 100.7 | 12 |
| Lowest-paying states | Index | Insurers |
|---|---|---|
| North Dakota (ND) | 93.1 | 6 |
| Nevada (NV) | 92.9 | 10 |
| Delaware (DE) | 92.7 | 7 |
| Maryland (MD) | 92.7 | 12 |
| Tennessee (TN) | 92.7 | 17 |
At the median contracted rate, this code models a −$6,345 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 902 priced contract cells across 51 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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