Statistical flags indicate unusual patterns — not proof of fraud or wrongdoing. Read our methodology

Procare Pharmacy Direct, Llc.

Pharmacy, Community/Retail Pharmacy·Monroeville, PA·NPI: 1043382302SharePrint Report
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Red Flags Explained

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Each flag represents a statistical test that identified unusual billing patterns. Here's what each flag on this provider means in plain English:

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Rate Outlier

Rate Outlier means this provider charges above the 90th percentile for multiple different procedure codes simultaneously. While one high-cost code could reflect specialization, consistently high rates across many codes may indicate systematic overbilling.

These flags are statistical indicators only. Many flagged providers have legitimate explanations for their billing patterns. Learn more about our methodology.

Risk Assessment

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Bills $2,871.26 per claim for J1726 — 3.6× the national median of $789.74.

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Bills $4,836.98 per claim for J1950 — 3.4× the national median of $1,442.37.

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Bills $2,731.20 per claim for J0178 (Injection, aflibercept, 1 mg) — 3.7× the national median of $730.09.

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Billing in the top 1% nationally for 4 procedure codes: J0584, J0178, J0775.

This is a statistical summary, not an accusation. See our methodology.

Active Billing Period:2018-01→2024-12(84 months)

Total Paid

$227.3M

$227,313,342

Total Claims

83K

Beneficiaries

67K

1.2 claims/patient

Avg Cost/Claim

$3K

#368 of 618K providers by total spending(top <0.1%)

🔍 Analysis

Provider Overview

Procare Pharmacy Direct, Llc. is a Pharmacy, Community/Retail Pharmacy provider based in Monroeville, PA. From the 2018–2024 period, this provider received $227.3M in Medicaid payments across 83K claims.

Why This Matters

This provider received $227.3M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 28,414 Medicaid beneficiaries for a full year at average per-enrollee costs.

↑ 142% growthsince first billing year

Monthly Spending Trend

Yearly Spending

2018
$14.1M
+59%
2019
$22.5M
+31%
2020
$29.5M
+40%
2021
$41.3M
+11%
2022
$45.8M
-13%
2023
$40.0M
-15%
2024
$34.1M

Procedure Breakdown

Cost per claim compared to national benchmarks

This provider bills for 30 distinct procedure codes. The top code (J0584 (Burosumab-twza (Crysvita) injection, 1 mg)) accounts for 32% of total spending.

J0584Top 1%

Burosumab-twza (Crysvita) injection, 1 mg

$72.4M

4K claims · 31.8%

Your Cost: $20,524.13/claim|Median: $15,993.89
1.3× median
J0638Normal range

$19.8M

910 claims · 8.7%

Your Cost: $21,803.97/claim|Median: $21,803.97
1.0× median
J1726Top 10%

$18.6M

6K claims · 8.2%

Your Cost: $2,871.26/claim|Median: $789.74
3.6× median
J7170Normal range

Emicizumab-kxwh (Hemlibra) injection, 0.5 mg

$16.6M

763 claims · 7.3%

Your Cost: $21,738.02/claim|Median: $23,418.64
0.9× median
J3285Normal range

$11.5M

3K claims · 5.1%

Your Cost: $4,178.96/claim|Median: $4,178.96
1.0× median
J7298Normal range

$10.8M

12K claims · 4.7%

Your Cost: $897.59/claim|Median: $751.11
1.2× median
J2357Top 5%

Injection, omalizumab, 5 mg

$10.0M

4K claims · 4.4%

Your Cost: $2,671.54/claim|Median: $920.37
2.9× median
J7307Normal range

Etonogestrel implant system, including implant and supplies

$8.3M

9K claims · 3.6%

Your Cost: $901.58/claim|Median: $786.43
1.1× median
J2323Top 5%

$6.5M

859 claims · 2.8%

Your Cost: $7,522.37/claim|Median: $2,797.07
2.7× median
J2182Top 5%

$5.5M

2K claims · 2.4%

Your Cost: $3,150.84/claim|Median: $1,614.23
1.9× median
J3380Top 5%

$5.3M

705 claims · 2.4%

Your Cost: $7,579.84/claim|Median: $4,027.41
1.9× median
J1950Top 10%

$5.1M

1K claims · 2.2%

Your Cost: $4,836.98/claim|Median: $1,442.37
3.4× median
J0490Top 10%

$4.8M

1K claims · 2.1%

Your Cost: $3,613.99/claim|Median: $1,422.77
2.5× median
J0585Top 10%

Injection, onabotulinumtoxinA, 1 unit

$4.5M

4K claims · 2.0%

Your Cost: $1,075.41/claim|Median: $470.36
2.3× median
J2350Top 5%

Ocrelizumab (Ocrevus) injection, 1 mg

$4.3M

137 claims · 1.9%

Your Cost: $31,409.95/claim|Median: $17,264.74
1.8× median
J0178Top 1%

Injection, aflibercept, 1 mg

$3.7M

1K claims · 1.6%

Your Cost: $2,731.20/claim|Median: $730.09
3.7× median
J2315Top 10%

$2.9M

2K claims · 1.3%

Your Cost: $1,364.14/claim|Median: $1,045.36
1.3× median
J0775Top 1%

$2.7M

271 claims · 1.2%

Your Cost: $9,858.31/claim|Median: $8,630.80
1.1× median
90378Normal range

$2.0M

838 claims · 0.9%

Your Cost: $2,383.40/claim|Median: $1,627.19
1.5× median
J2426Top 25%

$1.2M

585 claims · 0.5%

Your Cost: $2,048.95/claim|Median: $625.59
3.3× median
J0517Top 10%

$1.2M

252 claims · 0.5%

Your Cost: $4,683.83/claim|Median: $2,255.19
2.1× median
Q9992Top 25%

$1.1M

612 claims · 0.5%

Your Cost: $1,806.72/claim|Median: $1,537.34
1.2× median
J0180Normal range

$1.1M

51 claims · 0.5%

Your Cost: $21,038.91/claim|Median: $21,038.91
1.0× median
Q9991Top 25%

$930K

520 claims · 0.4%

Your Cost: $1,788.24/claim|Median: $1,554.42
1.1× median
J0897Top 10%

$802K

478 claims · 0.4%

Your Cost: $1,677.65/claim|Median: $493.25
3.4× median
J3590Top 5%

$709K

111 claims · 0.3%

Your Cost: $6,389.45/claim|Median: $24.77
257.9× median
J2356Top 1%

$661K

191 claims · 0.3%

Your Cost: $3,459.29/claim|Median: $1,828.61
1.9× median
J7296Normal range

$637K

700 claims · 0.3%

Your Cost: $910.03/claim|Median: $860.31
1.1× median
J0401Top 10%

$621K

309 claims · 0.3%

Your Cost: $2,008.61/claim|Median: $714.38
2.8× median
Q5103Top 5%

$493K

103 claims · 0.2%

Your Cost: $4,788.94/claim|Median: $1,075.28
4.5× median

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