Prolia (J0897): what insurers contract to pay

Denosumab · Hematology-Oncology

CareCost Research · Reviewed by Erin Rose

Prolia (J0897) carries a median commercial contracted rate of 98.0 on the Medicare ASP=100 index — 4.6% below the 102.7 typical-acquisition benchmark and 6.0% below the 104.3 Medicare payment line. 59 insurers report contracted rates across 52 states (1,063 priced cells), covering $1.98B in modeled Part B spend. It ranks #9 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 75.2 out of 100.

Contracted rate range across insurers

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), 85.8 (NADAC-measured acquisition, see below).

What each insurer contracts to pay

All 52 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 Nebraska	120.0	+16.8%	34	7
BlueCross BlueShield of South Carolina	118.0	+14.9%	55	6
BlueCross BlueShield of New Mexico	115.1	+12.1%	185	3
Regence Idaho	112.1	+9.2%	45	6
Regence Utah	109.4	+6.5%	50	5
BlueCross BlueShield of Arkansas	106.2	+3.4%	48	21
BCBS North Dakota	106.2	+3.4%	139	3
Blue Cross of Idaho	105.9	+3.1%	48	6
BlueCross BlueShield of Kansas	105.0	+2.2%	60	5
BlueCross BlueShield of Wyoming	104.7	+1.9%	44	7
Aetna	102.8	+0.1%	708	51
Premera Blue Cross	102.6	−0.1%	102	9
Anthem Massachusetts	101.7	−1.0%	64	25
BlueCross BlueShield of Louisiana	101.6	−1.1%	54	7
Blue Cross NC	101.6	−1.1%	187	52
Capital Blue Cross	101.6	−1.1%	92	35
HMSA (BCBS Hawaii)	101.3	−1.4%	80	3
Blue Shield of California	100.5	−2.1%	118	4
Anthem Wisconsin	98.0	−4.6%	139	5
Anthem Virginia	98.0	−4.6%	72	20
UnitedHealthcare	98.0	−4.6%	1,068	52
Harvard Pilgrim Health Care	98.0	−4.6%	229	10
Anthem Kentucky	98.0	−4.6%	71	10
Regence BlueCross BlueShield	98.0	−4.6%	56	14
BlueCross BlueShield of Massachusetts	98.0	−4.6%	60	7
BlueCross BlueShield of Oklahoma	98.0	−4.6%	79	2
Anthem Missouri	98.0	−4.6%	42	10
Regence Washington	97.9	−4.7%	75	5
Cigna	97.9	−4.7%	649	51
BlueCross BlueShield of Alabama	97.9	−4.7%	91	6
Anthem Maine	97.9	−4.7%	65	5
Anthem New York	97.9	−4.7%	72	15
Regence Oregon	97.9	−4.7%	58	7
Anthem Nevada	97.9	−4.7%	194	4
Florida Blue	97.9	−4.7%	32	5
Anthem Georgia	97.9	−4.7%	64	16
CareFirst BlueCross BlueShield	97.9	−4.7%	59	18
Anthem Connecticut	97.9	−4.7%	66	5
Centene	97.9	−4.7%	614	32
Kaiser Permanente	97.9	−4.7%	312	8
Anthem New Hampshire	97.9	−4.7%	49	7
Anthem Ohio	97.9	−4.7%	78	13
BlueCross BlueShield of Rhode Island	97.9	−4.7%	291	3
Anthem Indiana	97.9	−4.7%	136	25
Anthem California	97.7	−4.9%	64	4
Wellmark BCBS (Iowa/South Dakota)	97.6	−5.0%	78	10
BlueCross BlueShield of Tennessee	97.6	−5.0%	61	10
BlueCross BlueShield of Minnesota	97.6	−5.0%	68	7
BlueCross BlueShield of Texas	92.9	−9.5%	41	17
Horizon BCBS of New Jersey	92.4	−10.0%	42	6
BlueCross BlueShield of Michigan	90.7	−11.7%	63	7
BlueCross BlueShield of Arizona	82.2	−20.0%	38	19

The price history

Medicare's payment limit for Prolia moved +39.2% 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.

Part B utilization

Year	Part B spend	Dosage units (M)
2019	$1.60B	91.8
2020	$1.63B	88.9
2021	$1.78B	92.8
2022	$2.00B	93.8
2023	$2.19B	94.7
2024	$2.43B	—
2025	$1.98B	—

The margin picture

NADAC-measured acquisition cost for Prolia runs $23.87/unit as of 2026-01-07 — an acquisition index of 85.8 (ASP = 100).

At the median contracted index of 98.0, that implies a modeled gross margin of +12.2 points per ASP-unit — roughly +$3.46/unit at the latest ASP of $28.40.

Modeled from NADAC acquisition, medium confidence — your invoice price governs.

Where it pays most and least

Highest-paying states	Index	Insurers
Alaska (AK)	123.6	7
Idaho (ID)	110.7	12
Nebraska (NE)	109.7	9
Utah (UT)	105.9	12
Kansas (KS)	105.6	11

Lowest-paying states	Index	Insurers
Minnesota (MN)	97.9	13
Georgia (GA)	97.9	24
Pennsylvania (PA)	97.9	18
Mississippi (MS)	97.9	12
Iowa (IA)	97.9	10

Getting paid for it

Prior authorization required	83% of policies
Site-of-care steering	26% of policies
Pharmacy (white-bag) channel multiple	0.990×
Drug class	RANKL inhibitor

What this means in dollars

At the median contracted rate, this code models a −$4,541 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 1,063 priced contract cells across 59 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.

See also: Ocrevus · Xolair · Enhertu · report home · methodology