Evenity (J3111): what insurers contract to pay

Romosozumab-aqqg · Rheumatology

CareCost Research · Reviewed by Erin Rose

Evenity (J3111) carries a median commercial contracted rate of 95.7 on the Medicare ASP=100 index — 6.8% below the 102.7 typical-acquisition benchmark and 8.2% below the 104.3 Medicare payment line. 58 insurers report contracted rates across 52 states (1,049 priced cells), covering $651M in modeled Part B spend. It ranks #6 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 78.9 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	123.9	+20.6%	55	6
Regence Idaho	108.9	+6.0%	45	6
BlueCross BlueShield of Nebraska	107.7	+4.9%	34	7
Regence Utah	106.3	+3.5%	50	5
BCBS North Dakota	103.2	+0.5%	139	3
BlueCross BlueShield of Arkansas	103.1	+0.4%	48	21
BlueCross BlueShield of Kansas	101.9	−0.8%	60	5
BlueCross BlueShield of Louisiana	101.4	−1.3%	54	7
Blue Shield of California	100.8	−1.9%	118	4
Blue Cross NC	100.5	−2.1%	164	48
Blue Cross of Idaho	100.3	−2.3%	58	6
Premera Blue Cross	99.6	−3.0%	102	9
Anthem Massachusetts	99.4	−3.2%	64	25
Aetna	99.4	−3.2%	714	51
BlueCross BlueShield of Texas	99.3	−3.3%	46	22
Capital Blue Cross	98.7	−3.9%	92	35
HMSA (BCBS Hawaii)	97.9	−4.7%	69	4
Regence BlueCross BlueShield	95.7	−6.8%	57	14
Anthem Missouri	95.7	−6.8%	40	9
BlueCross BlueShield of Massachusetts	95.7	−6.8%	58	7
Anthem Wisconsin	95.7	−6.8%	154	5
Anthem Kentucky	95.7	−6.8%	92	8
Harvard Pilgrim Health Care	95.7	−6.8%	229	10
Anthem Virginia	95.4	−7.1%	72	20
Cigna	95.1	−7.4%	721	51
Regence Oregon	95.1	−7.4%	62	7
Anthem New York	95.1	−7.4%	72	15
Anthem Nevada	95.1	−7.4%	194	4
Kaiser Permanente	95.1	−7.4%	312	8
BlueCross BlueShield of Rhode Island	95.1	−7.4%	291	3
Anthem Indiana	95.1	−7.4%	136	25
Anthem Maine	95.1	−7.4%	65	5
BlueCross BlueShield of Alabama	95.1	−7.4%	91	6
UnitedHealthcare	95.1	−7.4%	1,080	51
CareFirst BlueCross BlueShield	95.1	−7.4%	59	18
Regence Washington	95.1	−7.4%	75	5
Florida Blue	95.1	−7.4%	32	5
Anthem Connecticut	95.1	−7.4%	66	5
Anthem Ohio	95.1	−7.4%	78	13
Anthem New Hampshire	95.1	−7.4%	49	7
Anthem Georgia	95.1	−7.4%	64	16
Anthem California	95.0	−7.5%	64	4
Wellmark BCBS (Iowa/South Dakota)	94.8	−7.7%	78	10
Centene	94.8	−7.7%	220	26
BlueCross BlueShield of Minnesota	94.8	−7.7%	69	6
BlueCross BlueShield of Tennessee	94.8	−7.7%	61	10
BlueCross BlueShield of Michigan	92.0	−10.4%	63	7
Horizon BCBS of New Jersey	90.2	−12.2%	42	6
BlueCross BlueShield of Arizona	79.9	−22.2%	38	19

The price history

Medicare's payment limit for Evenity moved +30.6% 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	$12M	1.4
2020	$118M	13.1
2021	$196M	21.4
2022	$297M	31.6
2023	$451M	45.3
2024	$639M	—
2025	$651M	—

Where it pays most and least

Highest-paying states	Index	Insurers
Alaska (AK)	109.2	7
Utah (UT)	102.9	11
Kansas (KS)	102.5	11
Nebraska (NE)	101.9	9
Arkansas (AR)	101.2	10

Lowest-paying states	Index	Insurers
Alabama (AL)	95.1	13
Nevada (NV)	95.1	12
Maryland (MD)	95.1	14
Iowa (IA)	95.1	9
Delaware (DE)	95.1	7

Getting paid for it

Prior authorization required	79% of policies
Site-of-care steering	21% of policies
Pharmacy (white-bag) channel multiple	1.020×
Drug class	sclerostin inhibitor

What this means in dollars

At the median contracted rate, this code models a −$6,774 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 1,049 priced contract cells across 58 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: Syfovre · Imfinzi · Enhertu · report home · methodology