COVERAGE COMPLETENESS AND TREATMENT COST ESTIMATION FOR ADMINISTERED DRUGS IN US COMMERCIAL PAYER PRICE TRANSPARENCY DATA
Author(s)
William P. Pajerowski, PhD1, Matthew Robben, BS2, Rafiq Ahmed, MBA3;
1Serif Health, Waban, MA, USA, 2Serif Health, Cincinnati, OH, USA, 3Serif Health, Los Angeles, CA, USA
1Serif Health, Waban, MA, USA, 2Serif Health, Cincinnati, OH, USA, 3Serif Health, Los Angeles, CA, USA
OBJECTIVES: Payer Transparency-in-Coverage (TiC) machine-readable files (MRFs) include negotiated in-network rates that may support research and decision-making for administered drugs. Evidence on completeness for HCPCS “J” codes and consistency for NDC-referenced drug rates is limited. We evaluated code coverage, reporting patterns, and reimbursement variation relative to Medicare Part B ASP.
METHODS: Our organization ingested TiC MRFs from 234 U.S. commercial payers posted in December 2025 and extracted negotiated rates for administered drugs. HCPCS coverage was assessed against active Level II HCPCS J-codes from CMS reference files. Commercial reimbursement was benchmarked to Medicare Part B Average Sales Price (ASP) limits using Q4 2024 ASP reference files. Outcomes included: (1) code-level presence (any rate observed), (2) payer-level reporting (share of payers with ≥1 in-network rate per code), (3) median number of in-network provider organizations associated per administered drug code, (4) commercial-to-ASP differentials (negotiated rate as a percent of Medicare reimbursement), (5) estimation and summary of treatment episode and plan-level costs (PMPM).
RESULTS: TiC MRFs captured essentially all active J-codes (97% of 1,085 HCPCS Codes reviewed), and most payers reported at least one in-network rate for the majority of J-codes ([Median_%_Payers_Per_Code], IQR [IQR]). Negotiated reimbursement varied widely relative to ASP (median ratio [Median_Ratio], p10-p90 [P10_Ratio]-[P90_Ratio]), with outliers above [X]× ASP observed in specific payer and site-of-care segments ([Pct_Codes_Above_X_ASP]%). Availability of provider identifiers and billing class fields differed by payer and file structure ([NPI/EIN/Billing_Class Completeness Placeholder]).
CONCLUSIONS: TiC MRFs provide near-complete HCPCS J-code coverage and enable large-scale assessment of commercial reimbursement variation compared with Medicare Part B ASP. The observed dispersion in negotiated rates across payers and settings supports use cases in contracting intelligence, market access research, and real-world economic evaluation. Continued improvements in file consistency and identifier completeness would further strengthen cross-payer comparability.
METHODS: Our organization ingested TiC MRFs from 234 U.S. commercial payers posted in December 2025 and extracted negotiated rates for administered drugs. HCPCS coverage was assessed against active Level II HCPCS J-codes from CMS reference files. Commercial reimbursement was benchmarked to Medicare Part B Average Sales Price (ASP) limits using Q4 2024 ASP reference files. Outcomes included: (1) code-level presence (any rate observed), (2) payer-level reporting (share of payers with ≥1 in-network rate per code), (3) median number of in-network provider organizations associated per administered drug code, (4) commercial-to-ASP differentials (negotiated rate as a percent of Medicare reimbursement), (5) estimation and summary of treatment episode and plan-level costs (PMPM).
RESULTS: TiC MRFs captured essentially all active J-codes (97% of 1,085 HCPCS Codes reviewed), and most payers reported at least one in-network rate for the majority of J-codes ([Median_%_Payers_Per_Code], IQR [IQR]). Negotiated reimbursement varied widely relative to ASP (median ratio [Median_Ratio], p10-p90 [P10_Ratio]-[P90_Ratio]), with outliers above [X]× ASP observed in specific payer and site-of-care segments ([Pct_Codes_Above_X_ASP]%). Availability of provider identifiers and billing class fields differed by payer and file structure ([NPI/EIN/Billing_Class Completeness Placeholder]).
CONCLUSIONS: TiC MRFs provide near-complete HCPCS J-code coverage and enable large-scale assessment of commercial reimbursement variation compared with Medicare Part B ASP. The observed dispersion in negotiated rates across payers and settings supports use cases in contracting intelligence, market access research, and real-world economic evaluation. Continued improvements in file consistency and identifier completeness would further strengthen cross-payer comparability.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
RWD83
Topic
Real World Data & Information Systems
Disease
STA: Biologics & Biosimilars, STA: Generics, STA: Genetic, Regenerative & Curative Therapies, STA: Multiple/Other Specialized Treatments, STA: Vaccines