The Infusion Reimbursement Index

You buy an infused drug for roughly its ASP. Medicare then pays you ASP + 6%. Most commercial insurers pay you less than that — so the contract that looks like your best business is often paying you below what the government does for the identical drug.

The Same-Drug Spread — how we measure it

For one drug in one state, line the insurers up by their middle contracted rate. The Same-Drug Spread compares an insurer near the top (the 90th percentile) with one near the bottom (the 10th), then takes the middle of that ratio across every drug-and-state market with enough insurers. It shows how far apart insurers are for the identical drug — without letting one outlier set the number.

The same drug, different pay

Start with one drug. Rituxan (rituximab), billed in TX. Here is what the highest- and lowest-paying insurers pay for it, next to Medicare (1.0×).

That is not a fluke. Below are the drugs with the widest gaps between insurers. Each line runs from the lowest-paying insurer to the highest. The dot is the middle. These are brand infusion drugs, the drugs most practices bill.

Rates below the typical acquisition benchmark

Break-even is not 1.0×. You rarely buy a drug at exactly its ASP, and Medicare does not pay 1.0× either. Measured against what a non-340B practice typically pays to acquire the drug — 1.027× ASP, per CMS's own ODACS survey — 85.0% of all Part B infusion spend is contracted below acquisition cost.

The measured-margin check

The 102.7 benchmark is a survey average, and a fair question is whether real invoices agree. For 77 drugs where acquisition cost is directly measured (NADAC), the median measured acquisition index is 97.7 — this subset skews toward multi-source drugs, which are bought below ASP, so it does not contradict the brand-heavy survey line. The finding that survives either benchmark: 44% of measured drugs have a median contracted rate below their own measured acquisition cost.

Measured acquisition from NADAC, monthly refresh; margin = median contracted index minus measured acquisition index, in ASP points. Your invoice governs.

The CareCost Buy-and-Bill Risk List

The 25 drugs with the greatest reimbursement exposure, scored 0–100 on Part B spend, the deficit against the acquisition benchmark, and how far apart payers sit. “Gap / $100k” is the modeled margin exposure per $100,000 of acquisition-benchmark drug cost — benchmark exposure, not your practice’s actual acquisition price.

The national market is squeezed. Is yours?

Pick your state, your dominant payer, and up to five drugs you buy and bill. We benchmark them against this corpus — in your browser, nothing leaves the page.

The 2026 Payer Reimbursement Scorecard

Insurer parent groups, ranked by what they pay (weighted by Medicare spend, so bigger drugs count more).

† thin book (under 10,000 publishable rates) — treat the grade as indicative, not comparable.

Geography is really payer identity

Some states look expensive — Wyoming’s median runs well above the national line. But hold the insurer constant and the geography disappears: within any single carrier operating in 20+ states, no state’s median differs from that carrier’s national median by more than 1.3% (most are within 0.1%). Fee schedules are effectively national. A “high-paying state” is a state whose local carrier pays high — which contract, not which map pin.

The hospital "premium" is largely a billing-form artifact

People say hospitals get paid ~30% more than offices for the same drug. That is not really true. Office and hospital claims use different billing forms, so it is not a fair match. When you compare the same billing form at both places, the gap is about +6%, not +32%. (n = 1,099 matched payer×state×drug pairs — a small matched set, stated as such.)

Your drugs, by specialty

Each drug is grouped by the specialty that gives it most. Cancer, eye, and rheumatology drugs are paid closest to Medicare. A wide gap between the middle and the top means the insurer you are on matters a lot.

Most drugs sit near Medicare. A few don't.

Inside the fee schedules: how all 37 filings actually price

The Same-Drug Spread exists because payers run three different pricing machines. Of 37 filings, thirty run a card system — about three rates per drug per state, 90%+ of practices on the standard one — or an outright posted price (Premera holds literally one rate in half its markets). Seven run a dispersed book: Blue Shield of California holds hundreds of rates per market (3.2× practice-to-practice spread), UnitedHealthcare ~47 (30% of practices off-card), with BCBS Arizona, Kaiser and the BCBS Federal Employee Program in between.

About 90% of Medicare drug dollars go to drugs paid 0.95–1.1× ASP. The big-money drugs are paid near Medicare. The high markups are on smaller drugs and on skin substitutes — a separate group we set aside because their prices are administratively set rather than ASP-anchored (91 skin-substitute codes: median 100, top decile 1.78×, max 9.2×).

The rate is only one of four levers

What an insurer pays is half the question. The other half is what it makes you do first, whether it is trying to move the infusion out of your office, and whether the pharmacy channel pays better. For 36 drugs we hold all four.

Every drug where we hold both

Infliximab: what each insurer prefers, and what it pays

Infliximab is the one drug here with real biosimilar competition, so it is the only place we can watch an insurer steer. A filled dot is the product the insurer prefers; a hollow ring is reachable only through step therapy.

Where the policy data stops

The first Part B drugs Medicare will ever negotiate

In January 2026 CMS selected the first physician-administered drugs for price negotiation. From January 2028 their benchmark stops being ASP+6% and becomes the negotiated Maximum Fair Price — and CMS will publish only 106% of MFP for them. This table is what commercial insurers pay for those drugs before that happens. There will be no other public before-picture.

Cite it, embed it, take the data

Everything here is CC BY 4.0 — reuse with attribution. Tables as CSV for your own analysis; the two headline graphics as embeds or a downloadable pack; the full dataset and method open.

• Data (CSV)
  Risk List · Payer Scorecard · Below acquisition · All drugs · Fee schedules
• Graphics
  Chart pack (zip) · Embed: Margin Stack · Embed: Carrier Scorecard
• For press
  Press page & quotable findings · Methodology · Full dataset · Checksums
• Contact
  press@carecostestimate.com
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Check your own drugs and state

Type a drug or pick your state. This runs in your browser — nothing is sent anywhere.

Data, methods, and how to cite this

Cite as: Licensed CC-BY 4.0 — reuse with credit. Download the PDF edition for filing or attachment.

The full drug table and the dataset download are in the lookup tool above (free with a work email). The methods below are open to everyone.

Words we use

ASP

Average Sales Price. The public Medicare drug price. Medicare pays ASP plus 6%.

× ASP

An insurer’s contracted rate divided by ASP, on a scale where ASP = 1.00 (or 100 as an index). Typical acquisition is about 1.027; Medicare pays 1.043 after sequestration, 1.06 by statute. A quick margin check — not a claims payment.

Buy-and-bill

You buy the drug, give it, then bill the insurer. Your margin is the pay minus what you paid.

The Same-Drug Spread

The 90th-percentile insurer's contracted rate divided by the 10th-percentile insurer's, for the same drug in the same state. We do not use highest-over-lowest: it grows mechanically with the number of insurers filing.

Publishable

Data that passed our quality check (enough separate practices, tied to ASP). Only this is used in the numbers.