Inside Medicaid's Most Expensive Drugs
J-codes are provider-administered drugs billed directly through Medicaid — injections, infusions, and therapies given in clinics and hospitals. Many cost over $10,000 per claim. Some treat rare diseases with tiny patient populations. The spending concentration is extreme.
$92K
Most expensive / claim
$3.46B
Total J-code spending
50
J-codes tracked
21
Avg providers / code
When most people think of drug costs, they think of prescriptions filled at a pharmacy. But some of the most expensive drugs in Medicaid never pass through a pharmacy counter. They're administered by providers — injected, infused, or implanted — and billed using HCPCS J-codes. These 50 codes represent some of the highest per-claim costs in the entire Medicaid system.
The most expensive: $92K per claim
Code J2326 (Nusinersen (Spinraza), 12 mg intrathecal injection) averages $92K per claim. Just 3 providers billed it, serving 983 beneficiaries for a total of $124.7M.
The spending concentration is striking. 14 of 50 codes cost more than $10,000 per claim, but together they account for billions in total spending. Many of these drugs treat rare or complex conditions — spinal muscular atrophy, hemophilia, multiple sclerosis — where a single injection can cost more than a year's rent.
Extreme provider concentration
Many of these drugs are billed by just 1–3 providers nationwide. The average J-code in this list is billed by only 21 providers, meaning a handful of specialty centers control access to — and billing for — the most expensive therapies Medicaid covers. This creates both monopoly pricing risk and fraud vulnerability.
The total Medicaid spend across these 50 J-codes is $3.46B, serving 400K beneficiaries. The biggest single code by total spending is J9271 (Injection, pembrolizumab, 1 mg) at $1.23B.
Context: These costs reflect real medical need
Many of these drugs are life-saving treatments for conditions with no alternatives. High per-claim costs don't automatically indicate waste or fraud — they reflect the reality of specialty pharmaceuticals. However, the extreme provider concentration and the magnitude of spending make these codes worth watching for billing anomalies.
All 50 Specialty J-Codes by Cost Per Claim
| # | Code | Description | Cost / Claim | Total Paid | Providers | Beneficiaries |
|---|---|---|---|---|---|---|
| 1 | J2326 | Nusinersen (Spinraza), 12 mg intrathecal injection | $92K | $124.7M | 3 | 983 |
| 2 | J1426 | Casimersen (Amondys 45) injection, 10 mg | $32K | $65.6M | 1 | 747 |
| 3 | J7189 | J7189 | $32K | $13.3M | 1 | 309 |
| 4 | J9042 | J9042 | $28K | $4.3M | 2 | 101 |
| 5 | J9348 | J9348 | $27K | $1.9M | 1 | 26 |
| 6 | J7170 | Emicizumab-kxwh (Hemlibra) injection, 0.5 mg | $24K | $247.0M | 13 | 8K |
| 7 | J0638 | J0638 | $22K | $19.8M | 1 | 793 |
| 8 | J0180 | J0180 | $21K | $1.1M | 1 | 36 |
| 9 | J1428 | Eteplirsen (Exondys 51) injection, 10 mg | $21K | $92.3M | 1 | 915 |
| 10 | J2350 | Ocrelizumab (Ocrevus) injection, 1 mg | $16K | $391.8M | 68 | 21K |
| 11 | J1951 | J1951 | $16K | $1.0M | 1 | 40 |
| 12 | J3241 | J3241 | $16K | $5.9M | 3 | 138 |
| 13 | J0584 | Burosumab-twza (Crysvita) injection, 1 mg | $16K | $168.4M | 7 | 6K |
| 14 | J3316 | J3316 | $15K | $11.5M | 2 | 649 |
| 15 | J7192 | Factor VIII (recombinant antihemophilic factor), per IU | $10K | $42.4M | 6 | 2K |
| 16 | J3245 | J3245 | $10K | $125K | 1 | 13 |
| 17 | J0775 | J0775 | $9K | $3.1M | 2 | 281 |
| 18 | J9317 | J9317 | $9K | $1.1M | 2 | 66 |
| 19 | J3357 | Ustekinumab (Stelara) injection, 1 mg | $8K | $21.4M | 7 | 2K |
| 20 | J9055 | J9055 | $7K | $4.6M | 3 | 382 |
| 21 | J2327 | J2327 | $7K | $183K | 2 | 26 |
| 22 | J1628 | J1628 | $6K | $276K | 1 | 37 |
| 23 | J9228 | J9228 | $6K | $320K | 2 | 26 |
| 24 | J9271 | Injection, pembrolizumab, 1 mg | $5K | $1.23B | 305 | 159K |
| 25 | J9047 | J9047 | $5K | $877K | 3 | 66 |
| 26 | J1557 | J1557 | $5K | $873K | 2 | 65 |
| 27 | J9354 | Ado-trastuzumab emtansine | $5K | $5.4M | 4 | 560 |
| 28 | J9316 | J9316 | $5K | $2.6M | 4 | 369 |
| 29 | J3285 | J3285 | $4K | $107.8M | 9 | 14K |
| 30 | J9358 | J9358 | $4K | $25.2M | 15 | 3K |
| 31 | J0716 | J0716 | $4K | $66K | 1 | 14 |
| 32 | J9022 | J9022 | $4K | $17.9M | 23 | 3K |
| 33 | J0791 | J0791 | $4K | $14.0M | 10 | 3K |
| 34 | J9299 | Nivolumab (Opdivo) injection, 1 mg | $4K | $218.8M | 96 | 32K |
| 35 | J8670 | J8670 | $4K | $63K | 1 | 13 |
| 36 | J0491 | J0491 | $4K | $4.4M | 11 | 1K |
| 37 | J9173 | J9173 | $4K | $11.2M | 18 | 2K |
| 38 | J7205 | J7205 | $4K | $4.8M | 1 | 103 |
| 39 | J3380 | J3380 | $3K | $141.2M | 101 | 33K |
| 40 | J7336 | J7336 | $3K | $41K | 1 | 12 |
| 41 | J2323 | J2323 | $3K | $180.2M | 90 | 49K |
| 42 | J9306 | J9306 | $3K | $77.0M | 48 | 14K |
| 43 | J9144 | J9144 | $3K | $67.1M | 44 | 13K |
| 44 | J0517 | J0517 | $3K | $10.5M | 16 | 3K |
| 45 | J7686 | J7686 | $3K | $16.8M | 3 | 4K |
| 46 | J1930 | J1930 | $3K | $2.6M | 6 | 824 |
| 47 | J9312 | J9312 | $3K | $84.1M | 85 | 17K |
| 48 | J2353 | J2353 | $3K | $9.8M | 13 | 3K |
| 49 | J9311 | J9311 | $3K | $2.1M | 1 | 515 |
| 50 | J1556 | J1556 | $3K | $171K | 1 | 24 |
Key Takeaways
- ▸The most expensive J-code (J2326) costs $92K per claim — billed by just 3 providers.
- ▸Total Medicaid spending on these 50 J-codes: $3.46B, serving 400K beneficiaries.
- ▸14 codes cost more than $10,000 per claim. Many are billed by fewer than 5 providers nationwide.
- ▸The average J-code is billed by only 21 providers — extreme concentration that warrants oversight.
Source: HHS Medicaid Provider Spending Data (2018–2024) · 227M records