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Drug Trend · Rheumatology · Endocrinology · Oncology
Every Medicare Part B payment limit CMS has published for J0897 — 59 quarters since Q1 2012, about 15 years of pricing on one axis, with the biosimilars alongside. Public CMS data with our change framing; no contracted rates.
Denosumab's payment limit roughly doubled from 2012 to 2025 — and then the biosimilar wave landed: four Q-codes entered the file across 2026, the leading entrant already pricing ~48% below the brand. This is the ustekinumab playbook running again, one year behind.
CMS payment limit (ASP + 6% basis) by quarter, as published.
Every code carries its own payment limit — same-molecule economics can differ by 50%+ between products.
| HCPCS | Product | In file since | Current limit | vs J0897 |
|---|---|---|---|---|
| Q5136 | Wyost/Jubbonti (denosumab-bbdz) | Q1 2026 | $27.665 | -8% |
| Q5157 | Ospomyv (denosumab-bmwo) | Q2 2026 | $25.979 | -14% |
| Q5158 | denosumab-bnht | Q2 2026 | $28.818 | -4% |
| Q5162 | Bomyntra/Conexxence (denosumab-nxxp) | Q2 2026 | $15.66 | -48% |
At the Q3 2026 limit of $30.101 per 1 mg, the implied ASP is about $28.397 and the on-paper add-on is $1.704 per 1 mg. After the 2% sequester on Medicare’s 80% share, the effective add-on is roughly 4.3% of ASP — about $1.221 per 1 mgwhen the full allowable is collected. Whether that covers your carrying cost, waste, and denials depends on your acquisition price against ASP — which is exactly the number the payment limit can’t see, and the comparison the practice X-Ray runs with your actuals.
Dose math. Prolia (osteoporosis): 60 mg SC every 6 months = 60 billing units; Xgeva (bone metastases): 120 mg every 4 weeks = 120 units — both bill under J0897 (1 mg/unit). At the Q3 2026 limit of $30.101 per 1 mg, a typical 60-unit dose carries a Medicare allowable of about $1,806.06 — Medicare pays ~$1,415.951 after the sequester, and ~$361.212 rides on coinsurance collection. Part B spent $2.19 billion on J0897 in 2023 across 680,070 beneficiaries (CMS Part B drug-spending data).
Administration. 96372 — therapeutic subcutaneous injection.
Waste modifiers. Single-dose container — JW (documented discard) / JZ (no waste) modifiers required since July 2023. Run your own numbers on the buy-and-bill calculator.
The coding & patient-cost side. This page covers the provider-margin story; for Prolia / Xgeva’s full billing reference — dosing conversions, modifiers, admin CPT detail, payer policies, and what the patient owes — see Prolia / Xgeva on CareCost Estimate, our billing-reference sister site.
Where J0897stands in the national payers’ published sourcing programs (the office-vs-hospital setting distinction most coverage misses):
State law is the other half: the white-bagging laws-by-state tracker — 11 states currently ban payer sourcing mandates outright.
All 59 published quarters for J0897, newest first, as published per file version.
| Quarter | Limit ($/1 mg) | QoQ |
|---|---|---|
| Q3 2026 | 30.101 | +2.0% |
| Q2 2026 | 29.507 | +0.2% |
| Q1 2026 | 29.457 | +0.3% |
| Q4 2025 | 29.38 | +0.5% |
| Q3 2025 | 29.237 | +5.1% |
| Q2 2025 | 27.809 | +0.6% |
| Q1 2025 | 27.656 | +2.6% |
| Q4 2024 | 26.96 | +0.8% |
| Q3 2024 | 26.749 | +6.2% |
| Q2 2024 | 25.189 | -0.0% |
| Q1 2024 | 25.198 | +4.1% |
| Q4 2023 | 24.217 | +0.1% |
| Q3 2023 | 24.192 | +5.1% |
| Q2 2023 | 23.018 | -0.2% |
| Q1 2023 | 23.067 | +2.5% |
| Q4 2022 | 22.51 | +1.1% |
| Q3 2022 | 22.255 | +4.7% |
| Q2 2022 | 21.26 | +0.3% |
| Q1 2022 | 21.205 | +0.1% |
| Q4 2021 | 21.189 | +1.0% |
| Q3 2021 | 20.972 | +4.4% |
| Q2 2021 | 20.094 | -0.1% |
| Q1 2021 | 20.107 | -0.1% |
| Q4 2020 | 20.123 | +1.1% |
| Q3 2020 | 19.901 | +2.9% |
| Q2 2020 | 19.338 | +0.3% |
| Q1 2020 | 19.278 | +0.0% |
| Q4 2019 | 19.276 | +0.9% |
| Q3 2019 | 19.104 | +2.2% |
| Q2 2019 | 18.69 | +0.4% |
| Q1 2019 | 18.611 | +0.2% |
| Q4 2018 | 18.58 | +1.1% |
| Q3 2018 | 18.378 | +2.5% |
| Q2 2018 | 17.937 | +1.1% |
| Q1 2018 | 17.749 | +2.4% |
| Q4 2017 | 17.332 | +1.7% |
| Q3 2017 | 17.035 | +2.4% |
| Q2 2017 | 16.629 | +0.7% |
| Q1 2017 | 16.517 | +1.8% |
| Q4 2016 | 16.227 | +0.7% |
| Q3 2016 | 16.113 | +3.2% |
| Q2 2016 | 15.61 | +0.8% |
| Q1 2016 | 15.489 | +1.7% |
| Q4 2015 | 15.235 | +0.7% |
| Q3 2015 | 15.13 | +2.9% |
| Q2 2015 | 14.707 | +0.1% |
| Q1 2015 | 14.685 | +1.7% |
| Q4 2014 | 14.446 | +0.0% |
| Q3 2014 | 14.439 | +0.8% |
| Q2 2014 | 14.323 | +0.3% |
| Q1 2014 | 14.286 | +0.9% |
| Q4 2013 | 14.153 | -0.0% |
| Q3 2013 | 14.159 | -0.4% |
| Q2 2013 | 14.219 | -0.4% |
| Q1 2013 | 14.271 | -0.3% |
| Q4 2012 | 14.321 | -0.5% |
| Q3 2012 | 14.392 | +0.0% |
| Q2 2012 | 14.392 | -0.3% |
| Q1 2012 | 14.429 | — |
Prolia / Xgeva (denosumab) is billed to Medicare Part B under HCPCS code J0897, with a billing unit of 1 mg. Total billed units depend on the administered dose.
Prolia (osteoporosis): 60 mg SC every 6 months = 60 billing units; Xgeva (bone metastases): 120 mg every 4 weeks = 120 units — both bill under J0897 (1 mg/unit). Administration is billed separately: 96372 — therapeutic subcutaneous injection.
At the Q3 2026 limit, a typical 60-unit dose carries an allowable of about $1,806.06. Medicare pays roughly $1,415.951 (80% less the 2% sequester) and the remaining ~$361.212 is patient or secondary coinsurance the practice still has to collect — before any administration revenue.
Yes. Prolia / Xgeva ships in single-dose containers, so since July 2023 CMS requires the JW modifier for documented discarded amounts and the JZ modifier when there is no waste. Missing modifiers are a common audit and denial trigger on this code.
$30.101 per 1 mg, effective July 1, 2026, per the CMS July 2026 ASP pricing file. That is up 2.0% from the prior quarter and up 3.0% year over year.
The archive holds 59 quarters for J0897, starting at $14.429 per 1 mg in Q1 2012. The all-time peak was $30.101 in Q3 2026; the current limit is $30.101.
The payment limit is set at ASP + 6% (currently implying an ASP of about $28.397 per 1 mg). After the 2% sequester on Medicare's 80% share, the effective add-on is roughly 4.3% — about $1.221 per 1 mg — when the full allowable is collected.
Wyost/Jubbonti (denosumab-bbdz) (Q5136): $27.665 per 1 mg, in the file since Q1 2026. Ospomyv (denosumab-bmwo) (Q5157): $25.979 per 1 mg, in the file since Q2 2026. denosumab-bnht (Q5158): $28.818 per 1 mg, in the file since Q2 2026. Bomyntra/Conexxence (denosumab-nxxp) (Q5162): $15.66 per 1 mg, in the file since Q2 2026. Each code carries its own payment limit, so same-molecule economics can differ sharply by product.
Which limits moved this quarter, across all drugs: the ASP-change leaderboard. How this data is built and verified: the Data Desk. Billing reference (dosing, modifiers, admin CPTs): CareCost Estimate’s drug library.
carecostoptimizer.com/drugs/prolia-j0897-asp-trend. Computed from the public-domain CMS ASP pricing files. Free to cite with attribution.Drug economics as of Q3 2026 (Medicare ASP basis)
The chart is the national price. The practice X-Ray runs J0897 against your acquisition cost, payer mix, and 835s — and prices the answer in dollars.