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

Alivia Specialty LLC

Pharmacy Specialty Pharmacy·Guaynabo, PR·NPI: 1306182548SharePrint Report
View on Risk Watchlist →

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.

Advanced Detection Signals

Additional statistical tests from advanced fraud detection methods

Change PointBilling shifted 5.0x in 2022-11

These signals use advanced statistical methods including digit distribution analysis, change-point detection, and market concentration metrics. Learn more.

Risk Assessment

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Bills $4,600.53 per claim for J9035 (Injection, bevacizumab, 10 mg) — 105.3× the national median of $43.71.

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Bills $2,675.47 per claim for J0897 (Injection, denosumab, one milligram) — 5.4× the national median of $493.25.

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Bills $2,952.47 per claim for Q5107 — 3.6× the national median of $824.41.

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Billing in the top 1% nationally for 11 procedure codes: J9035, J0897, J9358.

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

Active Billing Period:2019-10→2024-12(47 months)
Sharp billing drop in final month

Total Paid

$189.0M

$188,981,224

Total Claims

105K

Beneficiaries

71K

1.5 claims/patient

Avg Cost/Claim

$2K

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

🔍 Analysis

Provider Overview

Alivia Specialty LLC is a Pharmacy Specialty Pharmacy provider based in Guaynabo, PR. From the 2018–2024 period, this provider received $189.0M in Medicaid payments across 105K claims.

Why This Matters

This provider received $189.0M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 23,622 Medicaid beneficiaries for a full year at average per-enrollee costs.

↑ 39919% growthsince first billing year

Monthly Spending Trend

Yearly Spending

2019
$204K
+1518%
2020
$3.3M
-100%
2021
$203
+15160959%
2022
$30.8M
+138%
2023
$73.1M
+12%
2024
$81.6M

Procedure Breakdown

Cost per claim compared to national benchmarks

This provider bills for 30 distinct procedure codes. The top code (J9271 (Injection, pembrolizumab, 1 mg)) accounts for 31% of total spending.

J9271Top 10%

Injection, pembrolizumab, 1 mg

$58.9M

6K claims · 31.1%

Your Cost: $10,639.27/claim|Median: $5,391.55
2.0× median
J9035Top 1%

Injection, bevacizumab, 10 mg

$19.0M

4K claims · 10.0%

Your Cost: $4,600.53/claim|Median: $43.71
105.3× median
J9299Top 5%

Nivolumab (Opdivo) injection, 1 mg

$14.6M

2K claims · 7.7%

Your Cost: $8,999.70/claim|Median: $3,562.28
2.5× median
J9306Top 25%

Injection, pertuzumab, one milligram

$14.1M

2K claims · 7.5%

Your Cost: $5,938.10/claim|Median: $3,571.19
1.7× median
J9355Top 5%

Injection, trastuzumab, ten milligrams

$9.4M

2K claims · 5.0%

Your Cost: $4,690.51/claim|Median: $1,942.13
2.4× median
J0897Top 1%

Injection, denosumab, one milligram

$8.3M

3K claims · 4.4%

Your Cost: $2,675.47/claim|Median: $493.25
5.4× median
J9358Top 1%

$7.3M

715 claims · 3.9%

Your Cost: $10,192.80/claim|Median: $3,408.30
3.0× median
J9312Top 25%

$6.2M

1K claims · 3.3%

Your Cost: $5,365.58/claim|Median: $2,705.30
2.0× median
J2777Top 5%

$5.7M

2K claims · 3.0%

Your Cost: $2,387.24/claim|Median: $858.80
2.8× median
J9022Top 5%

$5.4M

540 claims · 2.8%

Your Cost: $9,914.12/claim|Median: $3,962.67
2.5× median
Q5107Top 5%

$4.6M

2K claims · 2.4%

Your Cost: $2,952.47/claim|Median: $824.41
3.6× median
J9042Top 1%

$4.0M

107 claims · 2.1%

Your Cost: $37,711.21/claim|Median: $21,549.29
1.8× median
J9145Top 1%

$3.9M

528 claims · 2.0%

Your Cost: $7,296.19/claim|Median: $651.46
11.2× median
Q5117Top 25%

$3.6M

1K claims · 1.9%

Your Cost: $2,427.85/claim|Median: $1,034.41
2.4× median
J9055Top 1%

$3.5M

446 claims · 1.9%

Your Cost: $7,841.21/claim|Median: $6,494.38
1.2× median
J9354Top 1%

$3.5M

520 claims · 1.8%

Your Cost: $6,719.75/claim|Median: $3,182.82
2.1× median
J2353Top 1%

Injection, octreotide, depot form, intramuscular, one milligram

$2.4M

473 claims · 1.3%

Your Cost: $5,136.57/claim|Median: $2,280.20
2.3× median
J1569Top 25%

$2.4M

780 claims · 1.3%

Your Cost: $3,088.31/claim|Median: $1,387.65
2.2× median
J9264Top 10%

$1.5M

221 claims · 0.8%

Your Cost: $6,851.14/claim|Median: $941.67
7.3× median
J0585Top 25%

Injection, onabotulinumtoxinA, 1 unit

$1.3M

1K claims · 0.7%

Your Cost: $906.14/claim|Median: $470.36
1.9× median
J9144Top 1%

$1.3M

94 claims · 0.7%

Your Cost: $13,386.01/claim|Median: $3,253.39
4.1× median
J9317Top 1%

$1.0M

76 claims · 0.6%

Your Cost: $13,739.12/claim|Median: $7,191.53
1.9× median
J3380Top 10%

Injection, vedolizumab, one milligram

$966K

146 claims · 0.5%

Your Cost: $6,616.75/claim|Median: $4,027.41
1.6× median
J9047Top 1%

$795K

97 claims · 0.4%

Your Cost: $8,194.75/claim|Median: $4,654.98
1.8× median
J0490Top 25%

$794K

238 claims · 0.4%

Your Cost: $3,335.84/claim|Median: $1,422.77
2.3× median
J9070Top 25%

$517K

2K claims · 0.3%

Your Cost: $301.94/claim|Median: $163.22
1.9× median
J9395Normal range

Injection, fulvestrant, twenty-five milligrams

$442K

1K claims · 0.2%

Your Cost: $433.82/claim|Median: $367.29
1.2× median
J9202Top 25%

$428K

599 claims · 0.2%

Your Cost: $714.30/claim|Median: $483.75
1.5× median
J2916Top 5%

$360K

2K claims · 0.2%

Your Cost: $146.47/claim|Median: $6.31
23.2× median
J0640Top 25%

$318K

5K claims · 0.2%

Your Cost: $66.55/claim|Median: $24.08
2.8× median

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