Enhertu (J9358): what insurers contract to pay

Fam-trastuzumab Deruxtecn-nxki · Hematology-Oncology

CareCost Research · Reviewed by Erin Rose

Enhertu (J9358) carries a median commercial contracted rate of 95.2 on the Medicare ASP=100 index — 7.3% below the 102.7 typical-acquisition benchmark and 8.7% below the 104.3 Medicare payment line. 58 insurers report contracted rates across 52 states (1,021 priced cells), covering $552M in modeled Part B spend. It ranks #1 of 25 on the CareCost Buy-and-Bill Risk List, with a risk score of 82.8 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 Nebraska	116.8	+13.7%	34	7
BlueCross BlueShield of South Carolina	112.4	+9.4%	55	6
Regence Idaho	109.0	+6.1%	45	6
Regence Utah	106.5	+3.7%	50	5
Regence Washington	104.7	+1.9%	75	5
Regence BlueCross BlueShield	104.6	+1.9%	56	14
BCBS North Dakota	103.3	+0.6%	139	3
BlueCross BlueShield of Arkansas	103.3	+0.6%	48	21
Blue Shield of California	102.0	−0.7%	118	4
Blue Cross NC	100.6	−2.0%	164	48
Aetna	100.0	−2.6%	546	51
Wellmark BCBS (Iowa/South Dakota)	99.8	−2.8%	78	10
Capital Blue Cross	98.8	−3.8%	92	35
Anthem Massachusetts	98.6	−4.0%	64	25
BlueCross BlueShield of Kansas	98.4	−4.2%	60	5
Anthem California	96.7	−5.8%	64	4
Premera Blue Cross	96.4	−6.1%	102	9
BlueCross BlueShield of Louisiana	96.1	−6.4%	54	7
Blue Cross of Idaho	95.8	−6.7%	67	6
BlueCross BlueShield of Minnesota	95.8	−6.7%	57	7
Anthem Nevada	95.2	−7.3%	194	4
UnitedHealthcare	95.2	−7.3%	1,080	51
Centene	95.2	−7.3%	102	25
Anthem Virginia	95.2	−7.3%	72	20
Anthem Connecticut	95.2	−7.3%	66	5
Florida Blue	95.2	−7.3%	32	5
BlueCross BlueShield of Rhode Island	95.2	−7.3%	291	3
Anthem Ohio	95.2	−7.3%	78	13
Anthem Indiana	95.2	−7.3%	136	25
Anthem New York	95.2	−7.3%	72	15
Regence Oregon	95.2	−7.3%	58	7
Anthem Georgia	95.2	−7.3%	64	16
Anthem New Hampshire	95.2	−7.3%	42	7
CareFirst BlueCross BlueShield	95.2	−7.3%	58	19
Anthem Maine	95.2	−7.3%	65	5
BlueCross BlueShield of Alabama	95.2	−7.3%	91	6
Kaiser Permanente	95.2	−7.3%	312	8
Cigna	95.2	−7.3%	721	51
BlueCross BlueShield of Massachusetts	95.1	−7.4%	43	4
Harvard Pilgrim Health Care	95.1	−7.4%	229	10
Anthem Wisconsin	95.1	−7.4%	154	5
Anthem Missouri	95.1	−7.4%	42	9
Anthem Kentucky	95.1	−7.4%	85	9
HMSA (BCBS Hawaii)	93.5	−9.0%	58	4
BlueCross BlueShield of Texas	92.4	−10.0%	39	8
BlueCross BlueShield of Michigan	92.2	−10.2%	63	7
BlueCross BlueShield of Tennessee	91.2	−11.2%	61	10
Horizon BCBS of New Jersey	87.9	−14.4%	44	6
BlueCross BlueShield of Arizona	80.0	−22.1%	38	19

The price history

Medicare's payment limit for Enhertu moved +27.1% 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)
2020	$37M	1.5
2021	$109M	4.5
2022	$258M	10.5
2023	$465M	18.2
2024	$582M	—
2025	$552M	—

Where it pays most and least

Highest-paying states	Index	Insurers
Alaska (AK)	105.9	7
Arkansas (AR)	103.3	9
Nebraska (NE)	103.2	9
Utah (UT)	102.6	11
Kansas (KS)	101.9	11

Lowest-paying states	Index	Insurers
District of Columbia (DC)	95.2	9
Indiana (IN)	95.2	15
Illinois (IL)	95.2	28
Maine (ME)	95.2	10
Pennsylvania (PA)	95.2	17

What this means in dollars

At the median contracted rate, this code models a −$7,291 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 1,021 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.