The Four Levers of Reimbursement

CareCost Research · Reviewed by Erin Rose

A payer has four independent knobs on what an infusion drug actually costs a practice or a patient: the contracted price, whether prior authorization gates the drug, whether a site-of-care program tries to move the infusion out of the office, and whether the drug is diverted to the pharmacy (white-bag) channel at a different price entirely. This note lays out all four, drug by drug, for the 36 drugs with a built dossier, then drills into the one drug — infliximab — with a public formulary tiering fight visible across insurers.

All 36 dossier drugs

Median index is the contracted rate at the middle insurer, expressed as a multiple of ASP × 100 (100 = Medicare's unmarked-up drug cost; the statutory add-on brings Medicare itself to about 106). Prior auth and steering are the share of insurers whose published policy requires them. Pharmacy channel is what the white-bag channel pays as a multiple of the medical-benefit rate, on the same ASP×100 scale — a flagged row means the figure rests on a thin sample and should not be quoted as a stable number.

Drug	Class	Part B spend	Median index (ASP=100)	Prior auth	Steering	Pharmacy channel
Denosumab J0897	RANKL inhibitor	$1,976M	98.0	83%	26%	99.0
Faricimab J2777	VEGF+Ang2 inhibitor	$1,771M	101.6	75%	10%	117.0
Aflibercept J0178	VEGF inhibitor	$1,230M	103.7	78%	17%	126.0
Abatacept J0129	T-cell costimulation modulator (CTLA-4 Ig)	$718M	97.6	90%	30%	302.0medium confidence
Romosozumab J3111	sclerostin inhibitor	$651M	95.7	79%	21%	102.0
Vedolizumab J3380	integrin (alpha4beta7) inhibitor	$574M	98.8	94%	39%	152.0
Ravulizumab J1303	C5 complement inhibitor	$535M	98.8	92%	32%	97.0
Ocrelizumab J2350	CD20-directed cytolytic antibody	$475M	97.8	92%	24%	117.0
Tocilizumab J3262	IL-6 receptor inhibitor	$348M	103.7	89%	37%	114.0
Efgartigimod alfa-fcab (Vyvgart) J9332	neonatal Fc receptor (FcRn) blocker	$337M	100.2	88%	35%	95.0
Rituximab J9312	CD20-directed cytolytic antibody	$327M	104.9	76%	24%	118.0
Omalizumab J2357	anti-IgE	$316M	97.7	93%	30%	104.0
Infliximab J1745	TNF-alpha inhibitor	$260M	103.0	86%	34%	240.0
Pegloticase J2507	PEGylated recombinant uricase	$241M	97.3	77%	41%	98.0
Golimumab (Simponi Aria) J1602	TNF-alpha inhibitor	$232M	105.4	92%	35%	323.0
Mepolizumab J2182	anti-IL-5	$210M	98.8	96%	24%	109.0
Benralizumab J0517	anti-IL-5Ralpha	$188M	99.2	96%	25%	113.0
Teprotumumab (Tepezza) J3241	IGF-1R (insulin-like growth factor-1 receptor) inhibitor	$164M	97.2	82%	18%	101.0
Lecanemab-irmb (Leqembi) J0174	anti-amyloid beta monoclonal antibody (IgG1)	$139M	99.9	100%	13%	93.0
Eculizumab J1299	C5 complement inhibitor	$138M	101.5	93%	33%	92.0
Secukinumab (Cosentyx IV) J3247	IL-17A inhibitor	$127M	99.1	88%	28%	92.0
Natalizumab J2323	alpha-4 integrin inhibitor	$115M	100.4	84%	24%	116.0
Belimumab J0490	B-lymphocyte stimulator (BLyS)-specific inhibitor	$104M	98.1	96%	26%	93.0
Risankizumab (Skyrizi IV) J2327	IL-23 (p19) inhibitor	$103M	102.8	96%	11%	116.0
Ferric Carboxymaltose (Injectafer) J1439	IV iron replacement (non-dextran carbohydrate-iron complex)	$91M	98.9	75%	17%	194.0
Eptinezumab J3032	calcitonin gene-related peptide (CGRP) antagonist monoclonal antibody	$77M	97.4	79%	38%	91.0
Donanemab-azbt (Kisunla) J0175	anti-amyloid beta monoclonal antibody (IgG1, targets N-truncated pyroglutamate amyloid-beta)	$74M	100.1	80%	13%	99.0
Inebilizumab (Uplizna) J1823	CD19-directed cytolytic antibody (anti-CD19 B-cell depleter)	$64M	97.0	90%	29%	94.0
Anifrolumab (Saphnelo) J0491	type I interferon (IFN) receptor antagonist (monoclonal antibody)	$63M	99.1	85%	25%	96.0
Ranibizumab J2778	VEGF inhibitor	$37M	132.8	91%	18%	574.0
Ublituximab J2329	CD20-directed cytolytic antibody	$34M	97.1	86%	33%	110.0
Guselkumab (Tremfya IV) J1628	IL-23 (p19) inhibitor	$19M	109.0	89%	11%	102.0medium confidence
Reslizumab J2786	anti-IL-5	$6M	98.3	92%	40%	95.0
Ustekinumab J3358	IL-12/23 (p40) inhibitor	$5M	110.0	93%	23%	126.0
Zoledronic acid J3489	bisphosphonate	$3M	156.8	73%	9%	151.0
Edaravone (Radicava) J1301	free radical scavenger (antioxidant)	$1M	270.3	95%	33%	18.0low confidence

Infliximab: the steering grid, payer by payer

Infliximab is the one drug in this dossier with enough parallel branded, biosimilar and alternate-biosimilar products on file to see formulary tiering directly. Each payer below lists every infliximab product with a published tier and its contracted index. A filled dot marks the preferred tier.

Payer	Infliximab products on file (index × 100, ASP = 100)
Blue Shield of California	● Avsola (Q5121) 88.9 ● Inflectra (Q5103) 101.8 ○ Remicade (J1745) 111.2 · step therapy ○ Renflexis (Q5104) 112.6 · step therapy
BlueCross BlueShield of Arkansas	● Avsola (Q5121) 104.4 ● Remicade (J1745) 111.8 ● Inflectra (Q5103) 168.1 ○ Renflexis (Q5104) 133.4 · step therapy
BlueCross BlueShield of Kansas	● Avsola (Q5121) 122.6 ● Inflectra (Q5103) 136.4 ○ Remicade† (J1745) 106.5 · step therapy ○ Renflexis† (Q5104) 112.7 · step therapy
BlueCross BlueShield of Louisiana	○ Avsola† (Q5121) 70.8 · step therapy ○ Renflexis† (Q5104) 108.5 · step therapy
BlueCross BlueShield of Massachusetts	● Avsola (Q5121) 91.0 ● Inflectra (Q5103) 94.0 ○ Remicade† (J1745) 103.0 · step therapy ○ Renflexis† (Q5104) 104.3 · step therapy
BlueCross BlueShield of Mississippi	● Inflectra (Q5103) 73.2 ● Remicade (J1745) 108.6
BlueCross BlueShield of Nebraska	● Avsola (Q5121) 87.4 ● Inflectra (Q5103) 99.0 ● Renflexis (Q5104) 118.1 ○ Remicade (J1745) 116.6 · step therapy
BlueCross BlueShield of South Carolina	● Inflectra (Q5103) 94.0 ● Renflexis (Q5104) 100.7 ○ Avsola† (Q5121) 91.0 · step therapy ○ Remicade† (J1745) 98.6 · step therapy
BlueCross BlueShield of Tennessee	○ Avsola† (Q5121) 64.9 · step therapy ○ Inflectra† (Q5103) 70.8 · step therapy ○ Remicade† (J1745) 98.8 · step therapy ○ Renflexis† (Q5104) 99.6 · step therapy
Capital Blue Cross	● Inflectra (Q5103) 89.0 ● Remicade (J1745) 106.9 ○ Avsola† (Q5121) 78.7 · step therapy ○ Renflexis† (Q5104) 106.2 · step therapy
Excellus BCBS	● Avsola (Q5121) 120.3 ● Inflectra (Q5103) 146.2 ○ Remicade (J1745) 98.8 · step therapy ○ Renflexis (Q5104) 101.4 · step therapy
HMSA (BCBS Hawaii)	● Avsola (Q5121) 112.7 ● Inflectra (Q5103) 127.6 ○ Renflexis† (Q5104) 152.2 · step therapy ○ Remicade† (J1745) 349.4 · step therapy
Kaiser Permanente	○ Remicade† (J1745) 144.2 · step therapy
Premera Blue Cross	● Avsola (Q5121) 102.3 ● Inflectra (Q5103) 107.2 ○ Remicade (J1745) 116.8 · step therapy ○ Renflexis (Q5104) 142.1 · step therapy
Regence BlueCross BlueShield	● Avsola (Q5121) 95.5 ● Inflectra (Q5103) 98.7 ○ Remicade (J1745) 103.5 · step therapy ○ Renflexis (Q5104) 105.7 · step therapy
UnitedHealthcare	● Avsola (Q5121) 112.5 ● Inflectra (Q5103) 144.7 ○ Remicade (J1745) 103.0 · step therapy ○ Renflexis (Q5104) 104.3 · step therapy
Wellmark BCBS (Iowa/South Dakota)	● Avsola (Q5121) 116.4 ● Inflectra (Q5103) 146.2 ○ Remicade† (J1745) 98.8 · step therapy ○ Renflexis† (Q5104) 101.4 · step therapy

● preferred tier · ○ non-preferred tier · † brand name inferred from the J-code (source left brand blank on this row; every other row using the same J-code in this dataset names the same product, so the mapping is unambiguous)

Does preferred tier mean insurers pay less?

Read this caveat before citing the steering numbers. The preferred-vs-non-preferred comparison rests on 19 policies — a small base. Paired by payer, preferred tiers pay less in 12 of 19 cases (median 107.2 vs 111.9, ASP = 100). That result is not statistically distinguishable from chance at this sample size, and it reverses sign when the same policies are compared unpaired instead of payer-by-payer. We report it paired, with its n stated plainly, and it carries no directional claim about whether steering saves insurers money.

Contracted rates from insurers’ machine-readable files, not amounts paid on a claim. Figures are drawn from report_data.json published alongside the Infusion Reimbursement Index and are not independently re-derived on this page.