Biologic Infusion Cost on Medicare in 2026: Part B vs. Part D Billing

Remicade, the brand name for infliximab, anchors a class of biologic infusion drugs that also includes Entyvio (vedolizumab), Orencia (abatacept), and Rituxan (rituximab). All four are monoclonal antibodies or fusion proteins delivered intravenously in a physician's office, hospital outpatient department, or freestanding infusion center to treat autoimmune conditions such as Crohn's disease, ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis. Because a clinician must administer the drug and monitor the patient during the one to three hour infusion, these drugs fall under Medicare Part B, the medical benefit, instead of Medicare Part D, the retail prescription drug benefit that covers self-injected biologics like Humira and Enbrel. That Part B versus Part D split determines the deductible, coinsurance, formulary tier, and prior authorization rules that apply to each drug, and it is the single biggest source of billing confusion for patients starting infusion therapy in 2026.

Medicare Part B reimburses infliximab using the Average Sales Price system: CMS's 2026 payment limit for HCPCS code J1745 (brand infliximab, excludes biosimilar) is $31.04 per 10 mg unit, which is the manufacturer's average sales price plus a 6 percent add-on. A standard 300 to 400 mg maintenance dose therefore reimburses providers roughly $930 to $1,240 for the drug alone, before separate facility and administration charges. Part B beneficiaries pay a $283 annual deductible in 2026, then 20 percent coinsurance on every infusion for the rest of the calendar year, unless a Medigap policy, employer retiree plan, or Medicaid covers the coinsurance. There is no annual out-of-pocket cap on Part B drug spending, which is very different from Medicare Part D, where the Inflation Reduction Act of 2022 set a $2,100 annual cap for 2026. Patients on chronic infusion therapy who lack supplemental coverage can face thousands of dollars in coinsurance exposure across a year of maintenance infusions every six to eight weeks.

CMS extended the Inflation Reduction Act's Medicare Drug Price Negotiation Program to Part B for the first time in the round announced for 2028 pricing, selecting Orencia and Entyvio, both biologic infusions in this same class, among the initial group of Part B drugs. Their negotiated Maximum Fair Prices take effect January 1, 2028, roughly two years after the first Part D Maximum Fair Prices took effect for drugs like Enbrel and Stelara on January 1, 2026. Infliximab and Remicade have not yet been selected for negotiation, so the main lever for lowering the Part B cost of infliximab today is competition from the three FDA-approved biosimilars: Inflectra, Renflexis, and Avsola. The CY2026 Hospital Outpatient Prospective Payment System final rule also extended Medicare's site-neutral payment policy to Part B drug administration codes, aligning off-campus hospital outpatient payment rates with the lower Medicare Physician Fee Schedule rate. CMS projects this will save Medicare and beneficiaries roughly $290 million in 2026 alone.

What Biologic Infusion Drugs Costs by Point of Pay (2026)

The price you pay depends almost entirely on WHERE you pay. The same biologic infusion drugs can cost many times more at a hospital than at your local pharmacy:

Why Hospitals Charge So Much

Hospital outpatient departments bill the identical infliximab infusion at two to five times the rate charged by a physician's office or freestanding infusion center, according to site-of-care research MedPAC has published for over a decade. MedPAC's 2023 analysis found the same chemotherapy-style infusion service reimbursed 186 percent higher when delivered in a hospital outpatient department than in a physician's office, a gap driven by hospital facility fees layered on top of the same drug acquisition cost. For a Part B biologic like Remicade, that markup applies to the administration and facility charge, not the drug's Medicare ASP rate, which is set nationally regardless of where the infusion happens. Independent infusion centers and physician offices operate on thinner margins and bill closer to the drug's actual acquisition cost, which is why patients without insurance often find infusion pricing several thousand dollars cheaper outside a hospital campus.

CMS's calendar year 2026 Hospital Outpatient Prospective Payment System final rule directly addresses this gap for the first time by extending Medicare's site-neutral payment policy to Part B drug administration codes at off-campus hospital outpatient departments. Starting in 2026, CMS pays these off-campus sites the lower Medicare Physician Fee Schedule rate for administering infusions like infliximab, Entyvio, Orencia, and Rituxan, instead of the higher hospital outpatient rate. CMS estimates the change will reduce total Medicare spending by about $290 million in 2026, with roughly $70 million of that returning to beneficiaries through lower coinsurance. Rural sole community hospitals are exempt from the policy, so patients in rural areas may still see the higher hospital-based charge.

Patients billed at a hospital outpatient rate for a biologic infusion should ask for an itemized bill separating the drug charge from the facility and administration charges, then compare the drug line to the 2026 Medicare ASP rate for the relevant HCPCS code. If a hospital charges a self-pay patient $15,000 for an infusion that an independent infusion center bills at $4,000 for the identical dose, that gap is facility markup, not the underlying cost of the biologic. Patients with commercial insurance should also ask whether an in-network independent infusion center or home infusion option is available, since many plans steer patients away from hospital outpatient sites specifically because of this cost differential.

HCPCS J-Codes: What Appears on Your Bill

Biologic infusions bill under distinct HCPCS Level II J-codes and Q-codes depending on the specific drug and whether the product is the brand or an FDA-approved biosimilar. A mismatched code is one of the most common Part B billing errors for this drug class:

Patient Assistance Programs

Janssen (Remicade's manufacturer), Takeda (Entyvio), Bristol Myers Squibb (Orencia), and Genentech (Rituxan) each operate a manufacturer copay program for commercially insured patients and a separate income-based patient assistance program for the uninsured:

Common Biologic Infusion Drugs Billing Errors

Biologic infusion bills carry more room for error than a retail prescription because they combine a drug charge, an administration charge, and often a facility fee on one claim. Check for these issues before paying:

• Brand infliximab (J1745) billed when a biosimilar (Inflectra, Renflexis, or Avsola) was actually infused. The biosimilar Q-codes reimburse at a different rate, so this mismatch can overcharge you or your insurer.
• Hospital outpatient facility fee stacked on top of a self-pay drug charge that already reflects the hospital's markup, effectively double-billing the same infusion.
• Prior authorization not renewed for a maintenance infusion series. Many payers require reauthorization every 6 to 12 months even when a patient has been stable on the same biologic for years.
• Charged full Part B coinsurance after the patient already met the $283 annual Part B deductible for 2026, or after a Medigap plan should have covered the 20% coinsurance.
• Manufacturer copay card or coupon incorrectly applied to a Medicare Advantage or Medicaid claim, which is prohibited and can trigger a clawback from the pharmacy or infusion center.
• Wrong administration CPT code, such as billing a routine maintenance infusion as a complex, higher-paying code, stacked with the drug charge to inflate the total bill beyond what CMS allows for the actual infusion time.

Frequently Asked Questions