Krystexxa (J2507): what insurers contract to pay

Pegloticase · Gastroenterology

CareCost Research · Reviewed by Erin Rose

Krystexxa (J2507) carries a median commercial contracted rate of 97.3 on the Medicare ASP=100 index — 5.3% below the 102.7 typical-acquisition benchmark and 6.7% below the 104.3 Medicare payment line. 57 insurers report contracted rates across 52 states (1,003 priced cells), covering $241M in modeled Part B spend. It ranks #15 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 70.1 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).

What each insurer contracts to pay

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	121.3	+18.1%	56	6
Regence Idaho	109.8	+6.9%	45	6
BlueCross BlueShield of Nebraska	108.6	+5.7%	34	7
Regence Utah	107.2	+4.4%	50	5
Blue Shield of California	104.6	+1.9%	101	4
BCBS North Dakota	104.1	+1.4%	139	3
BlueCross BlueShield of Arkansas	104.1	+1.4%	48	21
BlueCross BlueShield of Wyoming	103.1	+0.4%	44	7
Anthem Massachusetts	101.0	−1.7%	64	25
Blue Cross of Idaho	99.8	−2.8%	58	6
Aetna	99.8	−2.8%	788	51
Capital Blue Cross	99.5	−3.1%	92	35
BlueCross BlueShield of Kansas	99.2	−3.4%	60	5
Blue Cross NC	98.6	−4.0%	195	52
Premera Blue Cross	97.8	−4.8%	103	9
Regence BlueCross BlueShield	97.3	−5.3%	56	14
Anthem Missouri	97.3	−5.3%	42	9
Anthem Kentucky	97.3	−5.3%	85	9
Harvard Pilgrim Health Care	97.3	−5.3%	229	10
Anthem Wisconsin	97.3	−5.3%	96	6
Anthem Virginia	96.6	−5.9%	72	20
Anthem Indiana	95.9	−6.6%	136	25
Anthem Maine	95.9	−6.6%	65	5
Cigna	95.9	−6.6%	649	51
Anthem Georgia	95.9	−6.6%	64	16
Anthem New York	95.9	−6.6%	72	15
Anthem Nevada	95.9	−6.6%	194	4
Regence Oregon	95.9	−6.6%	58	7
Anthem Ohio	95.9	−6.6%	78	13
Kaiser Permanente	95.9	−6.6%	312	8
Anthem New Hampshire	95.9	−6.6%	49	7
BlueCross BlueShield of Rhode Island	95.9	−6.6%	291	3
BlueCross BlueShield of Alabama	95.9	−6.6%	91	6
Anthem Connecticut	95.9	−6.6%	66	5
Florida Blue	95.9	−6.6%	32	5
Regence Washington	95.9	−6.6%	75	5
CareFirst BlueCross BlueShield	95.9	−6.6%	58	19
UnitedHealthcare	95.9	−6.6%	1,080	51
BlueCross BlueShield of Louisiana	95.6	−6.9%	54	7
HMSA (BCBS Hawaii)	95.6	−6.9%	66	4
Centene	94.5	−8.0%	518	6
Anthem California	94.5	−8.0%	64	4
BlueCross BlueShield of Texas	94.0	−8.5%	47	10
Wellmark BCBS (Iowa/South Dakota)	93.2	−9.3%	78	10
BlueCross BlueShield of Minnesota	93.2	−9.3%	68	7
BlueCross BlueShield of Tennessee	93.2	−9.3%	61	10
BlueCross BlueShield of Michigan	92.8	−9.6%	63	7
Horizon BCBS of New Jersey	86.8	−15.5%	42	6
BlueCross BlueShield of Arizona	80.6	−21.5%	38	19

The price history

Medicare's payment limit for Krystexxa moved +28.8% 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	$113M	0.0
2020	$142M	0.1
2021	$160M	0.1
2022	$201M	0.1
2023	$247M	0.1
2024	$283M	—
2025	$241M	—

Where it pays most and least

Highest-paying states	Index	Insurers
Nebraska (NE)	108.6	8
Alaska (AK)	106.6	7
Idaho (ID)	105.2	12
Arkansas (AR)	104.1	9
Utah (UT)	103.1	12

Lowest-paying states	Index	Insurers
Maryland (MD)	95.9	13
Mississippi (MS)	95.9	11
Louisiana (LA)	95.9	9
Georgia (GA)	95.9	23
Nevada (NV)	95.9	11

Getting paid for it

Prior authorization required	77% of policies
Site-of-care steering	41% of policies
Pharmacy (white-bag) channel multiple	0.980×
Drug class	PEGylated recombinant uricase

What this means in dollars

At the median contracted rate, this code models a −$5,226 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 1,003 priced contract cells across 57 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.

See also: Entyvio · Polivy · Enhertu · report home · methodology