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Health & Medicine · a limn field note on CMS Medicare Part D

Where the
Prescriptions Go

Medicare Part D spends a quarter of a trillion dollars a year on drugs, and the money does not spread out - it pools. A dozen brands take the largest bites; one therapeutic idea has reshaped the whole branded market in a decade; and the opioids that draw the headlines turn out to concentrate by specialty far more than by state. Nine readings of one river of money, and where it lands.

$276B Part D drug spend, 2023
Claims filled
1.62B
Drug products
3,607
Opioid share
3.7%
Coverage
2013-2023
Curated CMS Medicare Part D Prescribers - by Geography and Drug

The opioid map

Fig. 01 · opioid claims as a share of all Part D claims

Opioids are a small slice of Part D claims nationally, but the rate is not spread evenly. It runs highest across the South and the Mountain West and lowest across the Northeast and mid-Atlantic - Alabama (5.4%) sits more than twice as high as New York (2.2%).

Alabama: 5.4% opioid claimsAlaska: 4.1% opioid claimsArizona: 4.3% opioid claimsColorado: 4.8% opioid claimsFlorida: 3.7% opioid claimsGeorgia: 4.5% opioid claimsIndiana: 4.4% opioid claimsKansas: 4.3% opioid claimsMaine: 3.5% opioid claimsMassachusetts: 2.9% opioid claimsMinnesota: 3.2% opioid claimsNew Jersey: 2.6% opioid claimsNorth Carolina: 4.4% opioid claimsNorth Dakota: 3% opioid claimsOklahoma: 5% opioid claimsPennsylvania: 3% opioid claimsSouth Dakota: 3.5% opioid claimsTexas: 3.8% opioid claimsWyoming: 4.6% opioid claimsConnecticut: 2.9% opioid claimsMissouri: 4.1% opioid claimsWest Virginia: 3.3% opioid claimsIllinois: 3.3% opioid claimsNew Mexico: 4% opioid claimsArkansas: 4.9% opioid claimsCalifornia: 3.5% opioid claimsDelaware: 3.9% opioid claimsDistrict of Columbia: 2.6% opioid claimsHawaii: 2.9% opioid claimsIowa: 3.3% opioid claimsKentucky: 4.5% opioid claimsMaryland: 4% opioid claimsMichigan: 4.4% opioid claimsMississippi: 4.2% opioid claimsMontana: 4.6% opioid claimsNew Hampshire: 3.2% opioid claimsNew York: 2.2% opioid claimsOhio: 3.3% opioid claimsOregon: 4.8% opioid claimsTennessee: 4.6% opioid claimsUtah: 5.4% opioid claimsVirginia: 3.5% opioid claimsWashington: 4.5% opioid claimsWisconsin: 3.5% opioid claimsNebraska: 3.5% opioid claimsSouth Carolina: 4.1% opioid claimsIdaho: 5.2% opioid claimsNevada: 4.8% opioid claimsVermont: 3.3% opioid claimsLouisiana: 4.4% opioid claimsRhode Island: 2.5% opioid claims
Opioid claim rate
  • < 3.5%
  • 3.5 - 4.0%
  • 4.0 - 4.5%
  • 4.5 - 5.0%
  • 5.0% +
No data
State-by-state table (51 rows, sorted high to low)
StateOpioid claim ratePart D spendClaims
Alabama 5.4% $5.09B 31M
Utah 5.4% $1.45B 9M
Idaho 5.2% $1.2B 8M
Oklahoma 5% $3.09B 19M
Arkansas 4.9% $2.55B 19M
Colorado 4.8% $3.41B 19M
Nevada 4.8% $1.87B 11M
Oregon 4.8% $2.81B 18M
Montana 4.6% $0.67B 5M
Tennessee 4.6% $6.89B 42M
Wyoming 4.6% $0.25B 2M
Georgia 4.5% $8.62B 51M
Kentucky 4.5% $4.88B 31M
Washington 4.5% $4.55B 28M
Indiana 4.4% $6.28B 38M
Louisiana 4.4% $4.52B 29M
Michigan 4.4% $9.4B 55M
North Carolina 4.4% $9.75B 57M
Arizona 4.3% $4.96B 29M
Kansas 4.3% $2.23B 15M
Mississippi 4.2% $2.65B 18M
Alaska 4.1% $0.39B 2M
Missouri 4.1% $5.75B 38M
South Carolina 4.1% $4.88B 28M
Maryland 4% $4.03B 21M
New Mexico 4% $1.23B 8M
Delaware 3.9% $0.9B 5M
Texas 3.8% $19.28B 108M
Florida 3.7% $20.29B 124M
California 3.5% $27.1B 146M
Maine 3.5% $1.47B 8M
Nebraska 3.5% $1.48B 10M
South Dakota 3.5% $0.65B 5M
Virginia 3.5% $5.54B 34M
Wisconsin 3.5% $4.73B 30M
Illinois 3.3% $9.23B 56M
Iowa 3.3% $2.41B 18M
Ohio 3.3% $10.85B 68M
Vermont 3.3% $0.54B 3M
West Virginia 3.3% $1.85B 12M
Minnesota 3.2% $3.95B 26M
New Hampshire 3.2% $1.13B 7M
North Dakota 3% $0.52B 4M
Pennsylvania 3% $13.21B 79M
Connecticut 2.9% $3.95B 19M
Hawaii 2.9% $0.92B 4M
Massachusetts 2.9% $7.22B 37M
District of Columbia 2.6% $0.62B 2M
New Jersey 2.6% $7.72B 40M
Rhode Island 2.5% $0.88B 6M
New York 2.2% $22.47B 106M

Full Real DY2023 ingest: Opioid_Drug_Flag = Y claims as a share of all Part D claims, rolled up per Prscrbr_Geo_Cd (state).

Fifty states, one gradient

Fig. 02 · states by opioid claim rate

The map colours space; this is the same data as a shape. Most states pile up just below and around the 4% mark - the median state sits at 4% - and then the distribution thins into a short, dark tail: only a handful of states clear 5%, but those are the ones the map paints deepest. Same buckets, same ramp as the map above.

< 3.5%: 16 states 16 < 3.5% 3.5-4.0%: 9 states 9 3.5-4.0% 4.0-4.5%: 12 states 12 4.0-4.5% 4.5-5.0%: 10 states 10 4.5-5.0% 5.0% +: 4 states 4 5.0% +
State counts by bucket (51 states)
Opioid claim rateStatesShare of states
< 3.5% (most common) 16 31%
3.5-4.0% 9 18%
4.0-4.5% 12 24%
4.5-5.0% 10 20%
5.0% + 4 8%

Full Real DY2023 ingest: the 51 states binned from the same per-state opioid rates as the map, on the identical thresholds.

The handful that dominates

Fig. 03 · top brand drugs by Part D spend, 2023

Part D is a river that pools in a few places. A single blood thinner, Eliquis, is the largest line item in the entire program - and the diabetes and obesity drugs stacked behind it are the fastest-climbing money in American medicine. Bar length is gross spend; the ledger beneath adds the tell that spend alone hides - cost per claim.

Eliquis Anticoagulant Eliquis: $18.3B $18.3B Ozempic GLP-1 diabetes Ozempic: $9.2B $9.2B Jardiance SGLT2 diabetes Jardiance: $8.8B $8.8B Trulicity GLP-1 diabetes Trulicity: $7.4B $7.4B Xarelto Anticoagulant Xarelto: $6.3B $6.3B Trelegy Ellipta Respiratory inhaler Trelegy Ellipta: $4.5B $4.5B Humira(Cf) Pen Autoimmune biologic Humira(Cf) Pen: $4.4B $4.4B Farxiga SGLT2 diabetes Farxiga: $4.3B $4.3B Januvia DPP-4 diabetes Januvia: $4.1B $4.1B Revlimid Cancer therapy Revlimid: $3.9B $3.9B Entresto Heart failure Entresto: $3.4B $3.4B Lantus Solostar Insulin Lantus Solostar: $3.2B $3.2B
Full ledger (spend, claims, beneficiaries, cost per claim)
DrugClassSpendClaimsBenef.Cost / claim
Eliquis Apixaban Anticoagulant $18.3B 21.2M 3.93M $862
Ozempic Semaglutide GLP-1 diabetes $9.2B 6.9M 1.46M $1,327
Jardiance Empagliflozin SGLT2 diabetes $8.8B 8.1M 1.88M $1,084
Trulicity Dulaglutide GLP-1 diabetes $7.4B 5.3M 0.94M $1,385
Xarelto Rivaroxaban Anticoagulant $6.3B 6.7M 1.32M $948
Trelegy Ellipta Fluticasone/Umeclidin/Vilanter Respiratory inhaler $4.5B 5M 1.05M $889
Humira(Cf) Pen Adalimumab Autoimmune biologic $4.4B 0.5M 0.06M $9,231
Farxiga Dapagliflozin Propanediol SGLT2 diabetes $4.3B 4.3M 0.99M $1,010
Januvia Sitagliptin Phosphate DPP-4 diabetes $4.1B 4M 0.84M $1,015
Revlimid Lenalidomide Cancer therapy $3.9B 0.2M 0.04M $17,852
Entresto Sacubitril/Valsartan Heart failure $3.4B 3.2M 0.66M $1,072
Lantus Solostar Insulin Glargine,hum.Rec.Anlog Insulin $3.2B 4.9M 1.2M $640

Full Real DY2023 ingest: national rows ranked by Tot_Drug_Cst (Eliquis led at $18.3B). Spend, claims, and beneficiary counts are the source values; the therapeutic-class tag beneath each name is a curator label.

Two economies of a blockbuster

Fig. 04 · cost per claim vs claim volume

The same top-of-the-leaderboard spend arrives two completely different ways. Down and to the right sit the maintenance drugs - Eliquis, the diabetes pills - filling tens of millions of prescriptions at a few hundred to a thousand dollars each. Up and to the left sit the specialty drugs - Revlimid, Humira - reaching a fraction as many people at four and five figures a fill. Bubble area is total spend.

Eliquis: $862 / claim, 21.2M claims, $18.3B spend Ozempic: $1,327 / claim, 6.9M claims, $9.2B spend Jardiance: $1,084 / claim, 8.1M claims, $8.8B spend Trulicity: $1,385 / claim, 5.3M claims, $7.4B spend Xarelto: $948 / claim, 6.7M claims, $6.3B spend Trelegy Ellipta: $889 / claim, 5M claims, $4.5B spend Humira(Cf) Pen: $9,231 / claim, 0.5M claims, $4.4B spend Farxiga: $1,010 / claim, 4.3M claims, $4.3B spend Januvia: $1,015 / claim, 4M claims, $4.1B spend Revlimid: $17,852 / claim, 0.2M claims, $3.9B spend Entresto: $1,072 / claim, 3.2M claims, $3.4B spend Lantus Solostar: $640 / claim, 4.9M claims, $3.2B spend

Reading: a maintenance drug and a specialty drug can post the same $3-5B in spend from opposite corners - one on volume, one on price. Both axes are log scaled to hold the 30x spread.

The two economies, as a table (sorted by cost per claim)
DrugCost / claimClaimsSpend
Revlimid $17,852 0.2M $3.9B
Humira(Cf) Pen $9,231 0.5M $4.4B
Trulicity $1,385 5.3M $7.4B
Ozempic $1,327 6.9M $9.2B
Jardiance $1,084 8.1M $8.8B
Entresto $1,072 3.2M $3.4B
Januvia $1,015 4M $4.1B
Farxiga $1,010 4.3M $4.3B
Xarelto $948 6.7M $6.3B
Trelegy Ellipta $889 5M $4.5B
Eliquis $862 21.2M $18.3B
Lantus Solostar $640 4.9M $3.2B

Full Real DY2023 ingest: cost per claim is Tot_Drug_Cst / Tot_Clms for each of the top national brand rows.

A short head, a long tail

Fig. 05 · cumulative share of spend by cumulative share of products

Part D covers more than 3,607 distinct drug products, but the money does not spread across them. Ranked most-expensive first, the top 10 drugs - 0.3% of the catalog - already take 26% of the spend, and the top 100 take 64%. The curve leaps off the origin and then crawls: the remaining thousands of products are a very long, very flat tail.

Top 0.3% of products = 27% of spendTop 1% of products = 45% of spendTop 2.6% of products = 63% of spendTop 5% of products = 75% of spendTop 13% of products = 90% of spendTop 30% of products = 98% of spendTop 60% of products = 100% of spendTop 100% of products = 100% of spend
Concentration by ranked cut (products vs spend)
Ranked cutShare of productsShare of spendCumulative spend
Top 10 drugs 0.3% 26% $71B
Top 100 drugs 2.8% 64% $176B
Top 500 drugs 13.9% 91% $250B
All drugs 100% 100% $276B

Full Real DY2023 ingest: cumulative Tot_Drug_Cst over the national drug list ranked most-expensive first (top 10 = 0.3% of products / 26% of gross spend; top 100 = 2.8% / 64%).

Where the dollars pool by class

Fig. 06 · therapeutic-class share of the branded tier

Group the branded tier by what the drugs are for and one family now dwarfs the rest. Diabetes & obesity - the GLP-1 and SGLT2 drugs and their diabetes cousins - is roughly 28% of branded spend on its own, more than anticoagulants and autoimmune biologics put together. A decade ago it would have been a sliver.

Diabetes & obesity: 28% ($71B) 28% Oncology & specialty: 23% ($58B) 23% Autoimmune & biologics: 17% ($43B) 17% Other brands: 17% ($43B) 17% Anticoagulants: 15% ($38B) 15%
  • Diabetes & obesity 28%
  • Oncology & specialty 23%
  • Autoimmune & biologics 17%
  • Other brands 17%
  • Anticoagulants 15%
Class breakdown (spend, share, representative brands)
Therapeutic familyShareSpendRepresentative brands
Diabetes & obesity 28% $71B Ozempic, Jardiance, Trulicity, Farxiga
Oncology & specialty 23% $58B Revlimid, Imbruvica, Biktarvy
Autoimmune & biologics 17% $43B Humira, Enbrel, Otezla
Other brands 17% $43B Trelegy, Dupixent, and the rest of the branded tier
Anticoagulants 15% $38B Eliquis, Xarelto

Illustrative The rest of this page is a real CMS ingest, but therapeutic-class families are a curator-added editorial layer (CMS ships no class column, and there is no reproducible "branded tier" boundary), so this split stays an illustrative stand-in anchored to the diabetes-drug surge.

Two curves, opposite ways

Fig. 07 · Part D spend and opioid share, 2013-2023

Across the decade the two headline numbers moved in opposite directions. Gross Part D spend more than doubled, from $104B to $276B, with the GLP-1 and SGLT2 class erupting from almost nothing to $36.8B - a rise steep enough to bend the whole program's total. Meanwhile the opioid share of claims slid from 5.8% to 3.7% as prescribing tightened. Two panels, one shared year axis; never a dual axis.

Gross Part D spend All drugs GLP-1 / SGLT2 class
$276B $36.8B
Opioid share of Part D claims percent of all claims
3.7%

Full Real ingest: national totals looped over every Geography-and-Drug vintage, 2013-2023. GLP-1/SGLT2 spend is the sum of Tot_Drug_Cst for that ingredient class; opioid share is Opioid_Drug_Flag = Y claims over all claims.

The class that ate the decade

Fig. 08 · share of branded spend, 2013 vs 2023

The same families, ten years apart. Anticoagulants and oncology drugs climbed; the old autoimmune giants ceded ground as biosimilars arrived. But one line runs away from the rest: Diabetes & obesity went from 9% of branded spend to 28% - a re-sorting of the whole branded market around a single therapeutic idea.

Diabetes & obesity 9% 28% Oncology & specialty 15% 23% Autoimmune & biologics 24% 17% Anticoagulants 6% 15%
Share shift by class (2013, 2023, change)
Therapeutic family20132023Change
Diabetes & obesity 9% 28% +19 pts
Oncology & specialty 15% 23% +8 pts
Autoimmune & biologics 24% 17% -7 pts
Anticoagulants 6% 15% +9 pts

Illustrative Like the class mix above, this slope rests on curator-defined families (no CMS class column), so the two endpoints stay illustrative stand-ins anchored to the documented GLP-1/SGLT2 surge and the biosimilar erosion of legacy biologics.

Who writes the opioids

Fig. 09 · opioid share of a specialty's Part D claims

The state map hides the sharper split. Opioid prescribing concentrates by specialty far more than by geography: interventional pain and pain management write opioids on a huge fraction of their claims, while primary care sits near the 3.6% national line. But volume flips the story - family practice alone files 404.9M claims, so the low-rate generalists still write most opioid prescriptions overall.

Interventional Pain Management Interventional Pain Management: 56% of claims are opioids 56% Pain Management Pain Management: 52.5% of claims are opioids 52.5% Anesthesiology Anesthesiology: 49.1% of claims are opioids 49.1% Physical Medicine & Rehab Physical Medicine & Rehab: 33.8% of claims are opioids 33.8% Orthopedic Surgery Orthopedic Surgery: 30% of claims are opioids 30% General Surgery General Surgery: 20.2% of claims are opioids 20.2% Emergency Medicine Emergency Medicine: 7.8% of claims are opioids 7.8% Hematology/Oncology Hematology/Oncology: 7% of claims are opioids 7% Dentist Dentist: 6.8% of claims are opioids 6.8% Nurse Practitioner Nurse Practitioner: 3.6% of claims are opioids 3.6% Family Practice Family Practice: 2.9% of claims are opioids 2.9% Internal Medicine Internal Medicine: 2.3% of claims are opioids 2.3%
Rate vs volume by specialty (the counterweight the bars hide)
SpecialtyOpioid ratevs nationalClaims
Interventional Pain Management 56% +52.4 pts 3.9M
Pain Management 52.5% +48.9 pts 5.2M
Anesthesiology 49.1% +45.5 pts 5M
Physical Medicine & Rehab 33.8% +30.2 pts 7.3M
Orthopedic Surgery 30% +26.4 pts 7.5M
General Surgery 20.2% +16.6 pts 3.3M
Emergency Medicine 7.8% +4.2 pts 15.6M
Hematology/Oncology 7% +3.4 pts 8.2M
Dentist 6.8% +3.2 pts 11.6M
Nurse Practitioner 3.6% +0 pts 286.6M
Family Practice 2.9% -0.7 pts 404.9M
Internal Medicine 2.3% -1.3 pts 366.1M

Full Real DY2023 ingest: opioid share (Opioid_Tot_Clms / Tot_Clms) volume-weighted by Prscrbr_Type over the ~1.4M-row companion by-Provider file. The twelve specialties shown are an editorial selection spanning the rate range.

Methodology

Notes on the Data

This dashboard is built on CMS Medicare Part D Prescribers - by Geography and Drug (Release RY2025 (data year 2023); trend 2013-2023), the public file CMS releases each year summarizing every drug paid for under Medicare Part D, aggregated to the national and state level. It reports total claims, total drug cost, beneficiary counts, and flags for opioids, long-acting opioids, antibiotics, and antipsychotics. "Drug cost" is the full amount paid - by the plan, the beneficiary, government subsidies, and any other payer - so it is gross spending, not net of the rebates manufacturers pay back.

What's real, what's a stand-in

Most of this page is now a real ingest, straight from the CMS bulk files. The national headline, the state opioid map and its distribution, the drug leaderboard, the price-versus-volume scatter, and the concentration curve are all rolled up from the DY2023 Geography-and-Drug file (115,936 rows). The 2013-to-2023 trend loops the national totals of all eleven Geography-and-Drug vintages. The opioid-rate-by-specialty reading is a volume-weighted roll-up of the companion by-Provider file, about 1.4 million prescriber rows. Those sections carry the Full badge. (The therapeutic-class tag beside each leaderboard drug is a curator label on real spend, since CMS ships no class column.)

Two readings remain editorial constructions and keep the Illustrative badge: the therapeutic-class mix and the 2013-to-2023 class slope. Both group brands into families - "diabetes and obesity," "anticoagulants," "autoimmune biologics" - that CMS does not ship as a column, and there is no reproducible "branded tier" boundary to anchor the shares to. A real all-drug roll-up would bury the story under a majority "other" bucket, so these two stay hand-curated stand-ins and are badged as such. That is why the site as a whole is marked Curated rather than Full: nearly everything is real, but these two cuts are not. We never present curated numbers as real.

What you're not seeing

Three big caveats. First, rebates: gross spend overstates what Medicare nets, and rebates are largest exactly on the brand blockbusters at the top of the leaderboard. Second, suppression: CMS blanks any aggregated cell built on fewer than 11 claims, so the smallest drugs and states are undercounted, not zero. Third, this is Part D only - drugs administered in a clinic and billed to Part B (many cancer infusions, for example) are not here, and neither is anyone outside Medicare. The opioid share counts claims, not milligrams or morphine-equivalents, so it measures how often opioids are dispensed, not how much.

Generated 2026-07-10 13:03 UTC

Source: CMS Medicare Part D Prescribers - by Geography and Drug

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