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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 headline price metric in the CMS Medicare Part D Drug Spending Dashboard, published annually on data.cms.gov and the primary dataset feeding every drug page on DrugPrice. CMS calculates it by dividing total Part D spending (plan payments + beneficiary cost sharing + manufacturer discounts) by the number of 30-day equivalent claims, giving a per-fill number that reflects real transaction economics rather than sticker price. The figure often diverges sharply from Wholesale Acquisition Cost (WAC) because it nets out PBM-negotiated rebates, coverage-gap manufacturer discounts, and Part D Low-Income Subsidy payments. For 2023 data (latest dashboard), specialty drugs like Humira averaged over $6,600 per claim while common generics like atorvastatin (generic Lipitor) averaged under $10. The metric is especially useful for tracking Inflation Reduction Act (IRA) impact: the 10 drugs entering negotiated pricing in 2026 (Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and the NovoLog/Fiasp insulin bundle) will show dramatic year-over-year drops in average cost per claim on the 2026 dashboard. CMS flags dashboard entries where total 2023 Medicare spending exceeded $500 million, making the metric a workable proxy for "most expensive drugs in Medicare." Average cost per claim does not equal what a cash-paying patient pays at the counter, that figure is closer to WAC minus any GoodRx or Cost Plus Drugs markdown.

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.
  • National Average Drug Acquisition Cost (NADAC), A CMS-published benchmark reflecting the actual average price retail pharmacies pay to acquire drugs from wholesalers, updated weekly.

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About This Definition

This definition is part of the DrugPrice Drug Pricing Glossary, 49 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.

this entity is one of the U.S. Medicare prescription-drug pricing concepts that recurs across this site. The definition above is the technical answer; the paragraphs below add the practical context for how the concept connects to the CMS Medicare Part D Drug Spending data data behind every per-entity page on the site.

In the CMS Medicare Part D Drug Spending data data, this concept shapes one or more of the fields that drive the per-entity grades and rankings on this site. The methodology page describes which fields feed into which output; this glossary entry documents the underlying term.

Source: CMS Medicare Part D Spending, 2026.