Q5116 Medicare Reimbursement Rate (2026)
Current CMS pricing and breakdown for Medical Code Description.
National Average Payment
Non-Facility (Private Office) Rate
Q5116 Reimbursement Rate History
| Quarter | Q1 2025 | Q2 2025 | Q3 2025 | Q4 2025 | Q1 2026 | Q2 2026 |
|---|---|---|---|---|---|---|
| National Average Payment | $18.97 | $24.93 | $28.62 | $27.99 | $8.21 | $10.43 |
ℹ️ Good to Know
This item has a standard price nationwide. Your local rate will likely match the amount shown above.
Code Description
Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg
Reimbursement Summary
CPT code Q5116 (Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg) had a 2026 Medicare non-facility reimbursement rate of $10.43. This reflects a -58.18% change from the prior year.
The 2026 National Medicare reimbursement for Q5116 is $10.43. This item is paid at a standard national rate, so local variation is typically minimal.
Description: Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg. Payment policies and coverage rules can still vary by setting and claim details, so confirm final guidance through CMS when needed.
Q5116 Reimbursement Rate History
| Quarter | Q1 2025 | Q2 2025 | Q3 2025 | Q4 2025 | Q1 2026 | Q2 2026 |
|---|---|---|---|---|---|---|
| National Average Payment | $18.97 | $24.93 | $28.62 | $27.99 | $8.21 | $10.43 |
Historical Medicare Reimbursement
| Quarter | Non-Facility Rate | Facility Rate | YoY % Change (Non-Fac) | YoY % Change (Fac) |
|---|---|---|---|---|
| 2026 Q2 | $10.43 | $10.43 | -58.18% | -58.18% |
| 2026 Q1 | $8.21 | $8.21 | -56.75% | -56.75% |
| 2025 Q4 | $27.99 | $27.99 | — | — |
| 2025 Q3 | $28.62 | $28.62 | — | — |
| 2025 Q2 | $24.93 | $24.93 | — | — |
| 2025 Q1 | $18.97 | $18.97 | — | — |
Commercial Payer Rates for Q5116
Pro FeatureNational average reimbursement from major commercial payers based on CMS Transparency in Coverage machine-readable files.
| Modifier | Place of Service | Avg. Rate | vs Medicare | Percentile Range |
|---|---|---|---|---|
| NULL | Office (11) | $91.46 | -4.0% | $80 — $104 |
| NULL | Telehealth (02) | $88.20 | -7.4% | $76 — $102 |
| NULL | Facility (21) | $79.31 | -15.6% | $68 — $95 |
| NULL | Outpatient Hospital (22) | $84.92 | -10.2% | $71 — $99 |
| NULL | Home (12) | $96.14 | +1.0% | $84 — $113 |
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Source: CMS Transparency in Coverage machine-readable files (MRFs). Commercial rates reflect payer-published negotiated amounts and may not reflect individual contracted rates.
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Facility vs. Non-Facility (Office) Payment
Facility vs. non-facility pricing most commonly applies to physician services paid under the RVU-based Physician Fee Schedule. For Q5116 (Drug / Biological), the payment methodology may not include both facility and non-facility rates.
Q2 2026 Breakdown
| Component | Office (Non-Fac) | Facility (Hosp) |
|---|---|---|
| Work RVU | ||
| Practice Expense (PE) | ||
| Malpractice (MP) | ||
| Total RVUs | 0.00 | 0.00 |
Learn How This Reimbursement Is Calculated
Medicare reimbursement is determined by RVUs, geographic adjustments, and the annual conversion factor.
Frequently Asked Questions
What is the 2026 Medicare rate for Q5116?
The 2026 National Average Medicare reimbursement rate for Q5116 (Drug / Biological) is $10.43. This rate is effective as of January 1, 2026.
What is the description for code Q5116?
Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg
Why do facility and non-facility payments differ for Q5116?
Facility vs. non-facility differences usually apply to RVU-based physician services. Q5116 may not use both facility and non-facility pricing depending on its payment methodology.
How can I find my local Medicare rate for Q5116?
Use MedFeeSchedule's Medicare Physician Fee Schedule Lookup Tool on the homepage to estimate your locality-adjusted reimbursement. Medicare payment can vary based on geographic adjustments (GPCI), place of service, and claim specifics.
Is Q5116 covered by Medicare?
Coverage depends on medical necessity, setting, and Medicare policy. Some codes may be bundled, contractor-priced, or restricted. Verify final coverage guidance through CMS or your local MAC when applicable.
