CareCost Medicare allows
$5.325
per unit · ASP+6%, Q4 2026
Original Medicare: the patient owes $695.03 for a 640 mg infusion
20% of the $3,475.14 Medicare allows for the drug and its administration, after the Part B deductible. A Medigap plan can take that to $0.
Estimate for your patient ↓Enter the dose and weight, pick the plan, and add a Medigap plan if there is one.
Indication sets the usual dose · Example: 80 kg at 8 mg/kg, type over it
Actemra's one-hour infusion bills 96365 alone; 96366 (each additional hour) needs more than 90 minutes and does not apply. Include the office visit only when a significant, separately identifiable E/M service is performed and documented (modifier 25).
| Item | Qty | Payer allows | Patient owes |
|---|---|---|---|
| Actemra (tocilizumab) J3262 | 640 | $3,408.00 | $681.60 |
| Infusion administration, initial hour 96365 | 1 | $67.14 | $13.43 |
| Total | $3,475.14 | $695.03 |
Medicare's 80% payment is reduced by the 2% sequester; the patient's 20% coinsurance is not affected.
The estimate above assumes the deductible is already met. Most patients are part-way through theirs for most of the year, and that changes what they owe today.
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Original Medicare · Actemra · 640 mg
Patient owes · deductible met
Commercial estimates use the payer’s published rate and this patient’s actual benefits.
$5.325 per mg is Part B's ASP+6% rate for Q4 2026. Once the $283 Part B deductible is met, the patient owes the remaining 20% coinsurance on the administered drug and the infusion, with no annual out-of-pocket maximum to cap it. A draw that pulls more from a vial than the dose needs is billed on its own discarded-drug line at the same rate. Full explanation: How Medicare Part B drug cost sharing works →
Rheumatoid arthritis starts at 4 mg/kg every 4 weeks and steps up to 8 mg/kg every 4 weeks based on clinical response, the worked example above; at that maintenance dose an 80 kg adult receives 13 infusions a year. Giant cell arteritis is dosed differently, at 6 mg/kg every 4 weeks with a tapering course of glucocorticoids. Every infusion bills the same way regardless of indication or interval.
The rheumatoid arthritis starting dose is 4 mg/kg, half the 8 mg/kg maintenance dose in the worked example above. For the same 80 kg patient that is 320 mg = 320 units, drawn from four 80 mg vials with nothing discarded. At Medicare's $5.325 per mg rate the drug line alone is $1,704.00, before the 96365 infusion and the patient's 20% coinsurance are added.
Giant cell arteritis is dosed at 6 mg/kg every 4 weeks, with a tapering course of glucocorticoids. The same 80 kg patient draws 480 mg = 480 units from one 400 mg and one 80 mg vial, again with no waste; the drug line at Medicare's rate is $2,556.00. The label does not recommend a GCA dose above 600 mg per infusion, so a patient over 100 kg is capped at 600 units.
Rheumatoid arthritis, cytokine release syndrome, and COVID-19 share an 800 mg ceiling per infusion; a patient whose weight would otherwise call for more is capped there, and 800 units is also the MUE on file for J3262, so a claim cannot exceed it. At the ceiling the drug line is $4,260.00, drawn from two 400 mg vials with no waste.
| Indication | Dose | Units | Vials drawn | Drug line (Medicare) |
|---|---|---|---|---|
| RA starting dose | 4 mg/kg | 320 | Four 80 mg vials | $1,704.00 |
| RA maintenance (worked example) | 8 mg/kg | 640 | One 400 mg + three 80 mg vials | $3,408.00 |
| GCA | 6 mg/kg | 480 | One 400 mg + one 80 mg vial | $2,556.00 |
| 800 mg ceiling (RA, CRS, COVID-19) | up to 8 mg/kg | 800 | Two 400 mg vials | $4,260.00 |
Every draw above is least-waste, so the JZ modifier applies throughout; a draw that leaves mg unused reports the remainder on a JW line instead, the same arithmetic the hub's widget example uses for a two-vial draw. The dose and vial math are built the same way at every visit: how the units and the JW/JZ line are built →
For the reference patient (80 kg, 8 mg/kg, 640 units, drug plus the 96365 infusion code), Medicare allows $3,475.14, and the Part B coinsurance on that is $695.03. Plans A, B, C, D, F, G, M and N cover Part B coinsurance in full, so once the deductible is met those patients owe nothing per infusion. Plans K and L do not: Plan K owes $347.51 once the deductible is met and $602.21 before it is; Plan L owes $173.76 and $442.61. Most patients meet the $283 deductible by their first infusion of the year, so the not-met figure applies only once regardless of how often Actemra is given afterward. See what each Medigap plan (A–N) owes on this claim →
| Plan | Covers Part B deductible ($283) | Covers Part B coinsurance | Patient owes, deductible met | Patient owes, deductible not met |
|---|---|---|---|---|
| Plan K | No | 50% | $347.51 | $602.21 |
| Plan L | No | 75% | $173.76 | $442.61 |
Only the letters that leave this patient a balance are listed. The full A–N grid, the high-deductible variants, Plan N’s office-visit carve-out and the MACRA restriction on Plans C and F are at Medigap Plans A–N.
Commercial payers negotiate their own rate for J3262, not ASP+6%: our corpus holds published rates from 37 of 37 payer files. Aetna’s median is $5.45 per unit against Medicare’s $5.325, putting the 640 mg worked example at $3,488.00 before benefits, close to the $3,408.00 Medicare allows for the same dose. Rates move by state as well as by payer, which is why the estimator above takes one. What the patient owes then depends on their specific benefits. Full explanation: How commercial drug reimbursement works →
Two tocilizumab biosimilars are priced lower this quarter: Tofidence at $4.706 per mg and Tyenne at $4.370 per mg, a gap several payers use as the reason to require a biosimilar before approving branded Actemra. See which payers require a biosimilar first →
Medicare pays the same ASP+6% rate for the Actemra drug itself no matter where it's infused. The difference is what gets billed alongside it: an office infusion bills the physician fee schedule's 96365 administration code and, when documented, a separate office visit (99214), the codes used in the estimator above, while a hospital outpatient department bills its own facility fee under the hospital outpatient prospective payment system instead of those physician-fee-schedule codes. Our data doesn't carry an Actemra-specific hospital-outpatient facility rate, so this estimator only prices the office/physician-fee-schedule path.
| Quarter | ASP+6% per mg |
|---|---|
| 2025 Q1 | $5.97 |
| 2025 Q2 | $5.88 |
| 2025 Q3 | $5.79 |
| 2025 Q4 | $5.71 |
| 2026 Q1 | $5.61 |
| 2026 Q2 | $5.53 |
| 2026 Q3 (current) | $5.41 |
On a commercial plan, the Genentech Co-pay Assistance Program brings the patient's cost to $5 per infusion, up to $15,000 a year; on the 640 mg worked example above, that is the difference between the $681.60 drug coinsurance the estimator shows and $5. It covers the drug line only: it does not touch the 96365 infusion administration or an office visit, and it excludes Medicare, Medicaid, and other government program patients.
On Medicare it does not apply at all, and none of the closed foundation funds that list Actemra help either: TotalAssist's Rheumatoid Arthritis fund ($4,000/year) and HealthWell's Giant Cell Arteritis or Temporal Arteritis Medicare Access fund ($4,500/year, checked June 11, 2026) are both closed, as is HealthWell's AutoImmune Medicare Access fund ($2,800/year). A Medigap plan is the only route to reduce the coinsurance on Medicare. See every program for this patient, with current status →
A patient who moves to the subcutaneous 162 mg syringe or ACTPen leaves this buy-and-bill claim entirely: it is a pharmacy-benefit product, priced and billed differently, and it is not approved for cytokine release syndrome or COVID-19.
For an 80 kg adult with rheumatoid arthritis at the 8 mg/kg maintenance dose (640 mg), Medicare allows $3,475.14 for the drug and its administration, and the patient's 20% coinsurance after the Part B deductible is $695.03.
$5.325 per mg under Part B's ASP+6% rate for Q4 2026. An 80 kg adult at 8 mg/kg needs 640 mg, drawn from one 400 mg and three 80 mg vials with nothing discarded, so Medicare's allowed amount is $3,408.00 for the drug plus $67.14 for the 96365 infusion.
No. The Genentech Co-pay Assistance Program brings the drug cost to $5 per infusion, up to $15,000 a year, but it covers the drug line only, not the 96365 infusion administration or an office visit. It also excludes Medicare, Medicaid, and other government program patients.
$5.325 per mg under Medicare's ASP+6% rate for Q4 2026. Aetna's commercial median across its published price files is close to that, at $5.45 per mg.
No. The Genentech Co-pay Assistance Program excludes Medicare, Medicaid, and other government program patients, and the foundation funds that list Actemra for rheumatoid arthritis, giant cell arteritis, and autoimmune conditions on Medicare are all closed. A Medigap plan is the only route to reduce the 20% coinsurance below what Original Medicare leaves.
Rheumatoid arthritis starts at 4 mg/kg, half the 8 mg/kg maintenance dose. For an 80 kg patient that is 320 mg = 320 units, drawn from four 80 mg vials, and the drug line at Medicare's rate is $1,704.00 before the increase to the 640 mg maintenance dose on clinical response.
Sources: CMS ASP pricing files (Q4 2026); Medicare physician fee schedule (96365, 99214, national non-facility); Medicare Part B deductible (2026); Medicare Rights Center 2026 Medigap plan benefits chart; 37 commercial payer published price files (Q2 2026); Genentech Co-pay Assistance Program and Genentech Patient Foundation (Free Drug) terms and status (public/programs-bundle.js, generated from the live programs corpus).
Reviewed September 21, 2026 by Erin Rose, CareCost Estimate founder. Methodology →