Romosozumab-aqqg · Rheumatology
Evenity (J3111) carries a median commercial contracted rate of 95.7 on the Medicare ASP=100 index — 6.8% below the 102.7 typical-acquisition benchmark and 8.2% below the 104.3 Medicare payment line. 58 insurers report contracted rates across 52 states (1,049 priced cells), covering $651M in modeled Part B spend. It ranks #6 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 78.9 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 | 123.9 | +20.6% | 55 | 6 |
| Regence Idaho | 108.9 | +6.0% | 45 | 6 |
| BlueCross BlueShield of Nebraska | 107.7 | +4.9% | 34 | 7 |
| Regence Utah | 106.3 | +3.5% | 50 | 5 |
| BCBS North Dakota | 103.2 | +0.5% | 139 | 3 |
| BlueCross BlueShield of Arkansas | 103.1 | +0.4% | 48 | 21 |
| BlueCross BlueShield of Kansas | 101.9 | −0.8% | 60 | 5 |
| BlueCross BlueShield of Louisiana | 101.4 | −1.3% | 54 | 7 |
| Blue Shield of California | 100.8 | −1.9% | 118 | 4 |
| Blue Cross NC | 100.5 | −2.1% | 164 | 48 |
| Blue Cross of Idaho | 100.3 | −2.3% | 58 | 6 |
| Premera Blue Cross | 99.6 | −3.0% | 102 | 9 |
| Anthem Massachusetts | 99.4 | −3.2% | 64 | 25 |
| Aetna | 99.4 | −3.2% | 714 | 51 |
| BlueCross BlueShield of Texas | 99.3 | −3.3% | 46 | 22 |
| Capital Blue Cross | 98.7 | −3.9% | 92 | 35 |
| HMSA (BCBS Hawaii) | 97.9 | −4.7% | 69 | 4 |
| Regence BlueCross BlueShield | 95.7 | −6.8% | 57 | 14 |
| Anthem Missouri | 95.7 | −6.8% | 40 | 9 |
| BlueCross BlueShield of Massachusetts | 95.7 | −6.8% | 58 | 7 |
| Anthem Wisconsin | 95.7 | −6.8% | 154 | 5 |
| Anthem Kentucky | 95.7 | −6.8% | 92 | 8 |
| Harvard Pilgrim Health Care | 95.7 | −6.8% | 229 | 10 |
| Anthem Virginia | 95.4 | −7.1% | 72 | 20 |
| Cigna | 95.1 | −7.4% | 721 | 51 |
| Regence Oregon | 95.1 | −7.4% | 62 | 7 |
| Anthem New York | 95.1 | −7.4% | 72 | 15 |
| Anthem Nevada | 95.1 | −7.4% | 194 | 4 |
| Kaiser Permanente | 95.1 | −7.4% | 312 | 8 |
| BlueCross BlueShield of Rhode Island | 95.1 | −7.4% | 291 | 3 |
| Anthem Indiana | 95.1 | −7.4% | 136 | 25 |
| Anthem Maine | 95.1 | −7.4% | 65 | 5 |
| BlueCross BlueShield of Alabama | 95.1 | −7.4% | 91 | 6 |
| UnitedHealthcare | 95.1 | −7.4% | 1,080 | 51 |
| CareFirst BlueCross BlueShield | 95.1 | −7.4% | 59 | 18 |
| Regence Washington | 95.1 | −7.4% | 75 | 5 |
| Florida Blue | 95.1 | −7.4% | 32 | 5 |
| Anthem Connecticut | 95.1 | −7.4% | 66 | 5 |
| Anthem Ohio | 95.1 | −7.4% | 78 | 13 |
| Anthem New Hampshire | 95.1 | −7.4% | 49 | 7 |
| Anthem Georgia | 95.1 | −7.4% | 64 | 16 |
| Anthem California | 95.0 | −7.5% | 64 | 4 |
| Wellmark BCBS (Iowa/South Dakota) | 94.8 | −7.7% | 78 | 10 |
| Centene | 94.8 | −7.7% | 220 | 26 |
| BlueCross BlueShield of Minnesota | 94.8 | −7.7% | 69 | 6 |
| BlueCross BlueShield of Tennessee | 94.8 | −7.7% | 61 | 10 |
| BlueCross BlueShield of Michigan | 92.0 | −10.4% | 63 | 7 |
| Horizon BCBS of New Jersey | 90.2 | −12.2% | 42 | 6 |
| BlueCross BlueShield of Arizona | 79.9 | −22.2% | 38 | 19 |
Medicare's payment limit for Evenity moved +30.6% 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 | $12M | 1.4 |
| 2020 | $118M | 13.1 |
| 2021 | $196M | 21.4 |
| 2022 | $297M | 31.6 |
| 2023 | $451M | 45.3 |
| 2024 | $639M | — |
| 2025 | $651M | — |
| Highest-paying states | Index | Insurers |
|---|---|---|
| Alaska (AK) | 109.2 | 7 |
| Utah (UT) | 102.9 | 11 |
| Kansas (KS) | 102.5 | 11 |
| Nebraska (NE) | 101.9 | 9 |
| Arkansas (AR) | 101.2 | 10 |
| Lowest-paying states | Index | Insurers |
|---|---|---|
| Alabama (AL) | 95.1 | 13 |
| Nevada (NV) | 95.1 | 12 |
| Maryland (MD) | 95.1 | 14 |
| Iowa (IA) | 95.1 | 9 |
| Delaware (DE) | 95.1 | 7 |
| Prior authorization required | 79% of policies |
| Site-of-care steering | 21% of policies |
| Pharmacy (white-bag) channel multiple | 1.020× |
| Drug class | sclerostin inhibitor |
At the median contracted rate, this code models a −$6,774 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 1,049 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.
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