Pegcetacoplan · Ophthalmology
Syfovre (J2781) carries a median commercial contracted rate of 96.2 on the Medicare ASP=100 index — 6.3% below the 102.7 typical-acquisition benchmark and 7.8% below the 104.3 Medicare payment line. 51 insurers report contracted rates across 52 states (902 priced cells), covering $339M in modeled Part B spend. It ranks #5 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 79.5 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 41 insurers with published rates for this code, ranked highest to lowest. Index is a multiple of Medicare ASP (ASP=100).
Medicare's payment limit for Syfovre moved -3.7% between Q4 2023 and Q2 2026. Because contracted rates are set as a multiple of ASP, a falling denominator drags every contracted rate down with it, typically with a two-quarter lag as CMS updates the published benchmark.
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) |
|---|---|---|
| 2023 | $77M | 0.5 |
| 2024 | $404M | — |
| 2025 | $339M | — |
| Highest-paying states | Index | Insurers |
|---|---|---|
| Alaska (AK) | 118.8 | 6 |
| Nebraska (NE) | 103.0 | 8 |
| Hawaii (HI) | 102.5 | 7 |
| Kansas (KS) | 101.0 | 10 |
| Washington (WA) | 100.7 | 12 |
| Lowest-paying states | Index | Insurers |
|---|---|---|
| North Dakota (ND) | 93.1 | 6 |
| Nevada (NV) | 92.9 | 10 |
| Delaware (DE) | 92.7 | 7 |
| Maryland (MD) | 92.7 | 12 |
| Tennessee (TN) | 92.7 | 17 |
At the median contracted rate, this code models a −$6,345 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 902 priced contract cells across 51 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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