Average Cost per Claim
The average amount Medicare pays per 30-day supply claim for a prescription drug, including both the plan's payment and the beneficiary's out-of-pocket cost.
How It Works
Average cost per claim is the primary price metric used in Medicare Part D drug spending data. It represents the total amount paid for a 30-day supply — combining what the insurance plan pays and what the patient pays out of pocket. This figure can vary significantly from the drug's list price (WAC) because it reflects negotiated rates, rebates, and cost-sharing. For expensive specialty drugs, the average cost per claim can exceed $10,000 per month, while common generics may cost under $10.
Related Terms
- Wholesale Acquisition Cost (WAC) — The manufacturer's list price for a drug sold to wholesalers — often called the "sticker price" before any rebates or discounts.
- Out-of-Pocket Cost — The amount a patient pays directly for a prescription drug — including copays, coinsurance, and deductible payments.
- Medicare Part D — The prescription drug benefit within Medicare, covering outpatient medications for 50+ million Americans aged 65+ and those with disabilities.
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About This Definition
This definition is part of the DrugPrice Drug Pricing Glossary — 34 terms explaining how prescription drug pricing works in the United States. All definitions are written in plain language for patients, caregivers, journalists, and healthcare professionals.