United Healthcare Pharmaceuticals
Compare United Healthcare's contracted rates for pharmaceuticals services against national averages and other major payers. Use these benchmarks to identify underpaid codes, prepare for contract renegotiations, and validate your reimbursement strategy.
UnitedHealthcare operates the largest commercial network in the U.S., with significant rate variation by metro market, product line, and provider tier.
Introduction
Pharmaceutical manufacturers rely on physician-administered drug reimbursement data to set pricing strategy, support market access, and understand how payers are actually paying for their products at the provider level. J-codes and Q-codes represent the buy-and-bill channel where physicians purchase drugs and seek reimbursement from payers — the reimbursement rate directly affects physician willingness to stock and administer a product.
Payer reimbursement for physician-administered drugs varies by methodology (ASP+%, WAC-based, or flat rate), site of service (hospital outpatient vs. physician office vs. infusion center), and plan type. Understanding real-world payer rates across therapeutic areas is critical for pricing decisions, contracting strategy, and identifying access barriers where underpayment may be driving physicians toward competitor products.
Oncology — Infused Chemotherapy & Immunotherapy
Checkpoint Inhibitors & Immunotherapy
PD-1/PD-L1 inhibitors and other immuno-oncology agents represent the fastest-growing segment of physician-administered oncology drugs. Payer reimbursement methodology (ASP+%, WAC-based, or carve-out) and site-of-service differentials directly affect physician buy-and-bill economics and product adoption.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J9271 | Injection, pembrolizumab, 1 mg | 0636 | Drugs requiring detailed coding | $62.41 |
| J9299 | Injection, nivolumab, 1 mg | 0636 | Drugs requiring detailed coding | $34.05 |
| J9228 | Injection, ipilimumab, 1 mg | 0636 | Drugs requiring detailed coding | $190.28 |
| J9173 | Injection, durvalumab, 10 mg | 0636 | Drugs requiring detailed coding | $87.83 |
Monoclonal Antibodies — Oncology
Targeted monoclonal antibody therapies used across solid tumor and hematologic malignancies. These high-cost agents are a key focus for payer formulary management and biosimilar substitution policies.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J9035 | Injection, bevacizumab, 10 mg | 0636 | Drugs requiring detailed coding | $78.54 |
| J9355 | Injection, trastuzumab, excludes biosimilar, 10 mg | 0636 | Drugs requiring detailed coding | $85.35 |
| J9312 | Injection, rituximab, 10 mg | 0636 | Drugs requiring detailed coding | $83.96 |
| J9305 | Injection, pemetrexed, not otherwise specified, 10 mg | 0636 | Drugs requiring detailed coding | $6.57 |
Chemotherapy Agents
Traditional cytotoxic chemotherapy drugs administered via infusion or injection. While many are now generic, branded formulations and novel combinations continue to be launched with differentiated payer coverage and reimbursement terms.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J9267 | Injection, paclitaxel, 1 mg | 0636 | Drugs requiring detailed coding | $0.29 |
| J9060 | Injection, cisplatin, powder or solution, 10 mg | 0636 | Drugs requiring detailed coding | $4.47 |
| J9045 | Injection, carboplatin, 50 mg | 0636 | Drugs requiring detailed coding | $9.37 |
| J9181 | Injection, etoposide, 10 mg | 0636 | Drugs requiring detailed coding | $1.86 |
Autoimmune & Inflammatory — Biologics
TNF Inhibitors & Anti-Inflammatory Biologics
Infused and injectable biologics for rheumatoid arthritis, Crohn’s disease, psoriasis, and other autoimmune conditions. This category has the most active biosimilar competition, with payer formulary positioning and reimbursement rates driving market share shifts between reference products and biosimilars.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J1745 | Injection, infliximab, excludes biosimilar, 10 mg | 0636 | Drugs requiring detailed coding | $36.19 |
| J0135 | Injection, adalimumab, 20 mg | 0636 | Drugs requiring detailed coding | $3,200.23 |
| J3380 | Injection, vedolizumab, 1 mg | 0636 | Drugs requiring detailed coding | $23.13 |
| J0717 | Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) | 0636 | Drugs requiring detailed coding | $5.33 |
Interleukin Inhibitors
IL-targeted biologics for psoriasis, psoriatic arthritis, and atopic dermatitis. Newer entrants in this class are competing on payer access and reimbursement favorability vs. established TNF inhibitors.
Hematology & Supportive Care
Erythropoiesis-Stimulating Agents & Colony-Stimulating Factors
ESAs and CSFs used to manage anemia and neutropenia in oncology and nephrology patients. These are among the most frequently administered physician-office drugs with well-established biosimilar alternatives and active payer-driven substitution programs.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J0885 | Injection, epoetin alfa, (for non-ESRD use), 1000 units | 0636 | Drugs requiring detailed coding | $8.86 |
| J0881 | Injection, darbepoetin alfa, 1 microgram (non-ESRD use) | 0636 | Drugs requiring detailed coding | $3.64 |
| J2505 | 0636 | Drugs requiring detailed coding | — | |
| J1442 | Injection, filgrastim (G-CSF), excludes biosimilars, 1 microgram | 0636 | Drugs requiring detailed coding | $1.09 |
Iron & Blood Products
IV iron formulations and blood-derived products administered in infusion centers, dialysis units, and physician offices. Multiple branded IV iron products compete on infusion time, dosing convenience, and payer-specific reimbursement rates.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J1756 | Injection, iron sucrose, 1 mg | 0636 | Drugs requiring detailed coding | $0.61 |
| J1439 | Injection, ferric carboxymaltose, 1 mg | 0636 | Drugs requiring detailed coding | $1.19 |
| J1750 | Injection, iron dextran, 50 mg | 0636 | Drugs requiring detailed coding | $18.10 |
| Q0138 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use) | 0636 | Drugs requiring detailed coding | $0.48 |
Bone & Musculoskeletal
Osteoporosis & Bone-Modifying Agents
Injectable and infused bone-targeted therapies for osteoporosis and skeletal-related events in oncology. Payer coverage policies and step therapy requirements significantly influence product selection in this category.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J0897 | Injection, denosumab, 1 mg | 0636 | Drugs requiring detailed coding | $29.06 |
| J3489 | Injection, zoledronic acid, 1 mg | 0636 | Drugs requiring detailed coding | $18.84 |
| J3111 | Injection, romosozumab-aqqg, 1 mg | 0636 | Drugs requiring detailed coding | $11.46 |
Joint Injections — Viscosupplementation & Corticosteroids
Intra-articular injections for osteoarthritis and inflammatory joint conditions. Hyaluronic acid products and corticosteroid injections are high-volume physician-administered products with significant Q-code and J-code billing variation.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J7321 | Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose | 0636 | Drugs requiring detailed coding | $80.60 |
| J7325 | Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg | 0636 | Drugs requiring detailed coding | $10.80 |
| J1020 | Injection, methylprednisolone acetate, 20 mg | 0636 | Drugs requiring detailed coding | $7.60 |
| J1030 | Injection, methylprednisolone acetate, 40 mg | 0636 | Drugs requiring detailed coding | $8.36 |
Ophthalmology — Intravitreal Injections
Anti-VEGF & Retinal Therapies
Intravitreal anti-VEGF injections for wet AMD, diabetic macular edema, and retinal vein occlusion. This is one of the highest-spend physician-administered drug categories, with active competition between branded products, biosimilars, and off-label compounded alternatives. Payer reimbursement rates directly affect retina specialist product selection.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| J2778 | Injection, ranibizumab, 0.1 mg | 0636 | Drugs requiring detailed coding | $156.23 |
| J0178 | Injection, aflibercept, 1 mg | 0636 | Drugs requiring detailed coding | $848.34 |
| J0179 | Injection, brolucizumab-dbll, 1 mg | 0636 | Drugs requiring detailed coding | $340.27 |
| J9035 | Injection, bevacizumab, 10 mg | 0636 | Drugs requiring detailed coding | $78.54 |
Drug Administration Services
Infusion & Injection Administration Codes
Administration codes billed alongside the drug product to cover facility, nursing, and supplies costs. Administration reimbursement affects the total economics of the buy-and-bill model and varies significantly by site of service and payer.
| Billing Code | Description | Revenue Code | Description | Avg. National UHC Rate |
|---|---|---|---|---|
| 96365 | Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); Initial, Up To 1 Hour | 0260 | IV therapy | $90.89 |
| 96366 | Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); Each Additional Hour (List Separately In Addition To Code For Primary Procedure) | 0260 | IV therapy | $27.84 |
| 96374 | Therapeutic, Prophylactic, Or Diagnostic Injection (Specify Substance Or Drug); Intravenous Push, Single Or Initial Substance/Drug | 0260 | IV therapy | $59.67 |
| 96372 | Therpeutic, Prophylactic Or Diagnostic Injection {Specify Substance Or Drug}; Subcutaneous Or Intramuscular Nurse Pracitioner Rendering Service In Collaborati | 0260 | IV therapy | $20.37 |
What is a fee schedule?
A fee schedule is a list of negotiated prices that healthcare providers charge for specific services. These prices vary by payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the applicable fee schedule helps providers optimize billing for accurate reimbursement and helps patients anticipate out-of-pocket costs.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts.
Private Insurance Rates
Negotiated rates between providers and insurance companies.
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
View pharmaceuticals fee schedules for other major payers
What is Price Transparency?
The federal Price Transparency Rule took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). This landmark regulation mandates that insurance companies make healthcare costs transparent to the public. Read more here.
PayerPrice gives you access to the actual prices that insurers are legally required to publish under the Price Transparency Rule. We deliver this data exactly as reported in the insurers' machine-readable files, giving you an accurate view of negotiated rates. While insurers occasionally report incomplete or inaccurate data, our platform ensures you see the same information that insurers have made publicly available.
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