Module E: budget impact

Exploration notebook, module E: existing outputs only, no new analysis

Back to the report · Project site · Interactive budget model

Central five-year net cost $161.3 million ($2.69 per enrollee per month) for 1 million enrollees, rebate 51.2% assumed.

Scenarios

y35 price five_year_gross five_year_net five_year_prescriptions pmpm_net pmpm_gross net_cost_per_member_year_continuous net_cost_per_user_year n_years_exceed_pool
plateau rebate low (23.1%) 330723799 254326602 278807.2 4.24 5.51 10946.34 3958.93 0
growth rebate low (23.1%) 480384613 369415767 404974.5 6.16 8.01 10946.34 3958.93 0
decline rebate low (23.1%) 269435667 207196028 227140.0 3.45 4.49 10946.34 3958.93 0
plateau rebate central 330723799 161317183 278807.2 2.69 5.51 6943.17 2511.11 0
growth rebate central 480384613 234317254 404974.5 3.91 8.01 6943.17 2511.11 0
decline rebate central 269435667 131422664 227140.0 2.19 4.49 6943.17 2511.11 0
plateau rebate high (implied by $245) 330723799 68307764 278807.2 1.14 5.51 2940.00 1063.30 0
growth rebate high (implied by $245) 480384613 99218740 404974.5 1.65 8.01 2940.00 1063.30 0
decline rebate high (implied by $245) 269435667 55649300 227140.0 0.93 4.49 2940.00 1063.30 0
plateau announced $245 330723799 68307764 278807.2 1.14 5.51 2940.00 1063.30 0
growth announced $245 480384613 99218740 404974.5 1.65 8.01 2940.00 1063.30 0
decline announced $245 269435667 55649300 227140.0 0.93 4.49 2940.00 1063.30 0
pa_multiplier five_year_net five_year_gross pmpm_net label
0.50 80658591 165361900 1.34 tight PA (assumption)
0.75 120987887 248042850 2.02 tight PA (assumption)
1.00 161317183 330723799 2.69 PA as observed in the 10 covering states (central)
1.25 201646479 413404749 3.36 loose PA (assumption)
year prescriptions gross net pmpm_net pmpm_gross treated_member_years net_cost_per_member_year_continuous treated_members net_cost_per_user_year eligible_pool exceeds_pool
1 19731.4 23405578 11416541 0.95 1.95 1644.28 6943.17 4546.41 2511.11 300948.3 FALSE
2 52407.0 62165691 30322566 2.53 5.18 4367.25 6943.17 12075.35 2511.11 300948.3 FALSE
3 68889.6 81717510 39859359 3.32 6.81 5740.80 6943.17 15873.18 2511.11 300948.3 FALSE
4 68889.6 81717510 39859359 3.32 6.81 5740.80 6943.17 15873.18 2511.11 300948.3 FALSE
5 68889.6 81717510 39859359 3.32 6.81 5740.80 6943.17 15873.18 2511.11 300948.3 FALSE

Grouped bars of five-year net budget impact for three years 3-5 scenarios and four rebate or price assumptions, from 55.6 to 369.4 million dollars.

Cost by scenario

Sensitivity

parameter low_label high_label net_low net_high span
Coverage effect (95% CI) lower CI upper CI 63708574 258925907 195217333
Rebate share 79.3% (implied by $245) 23.1% (statutory minimum) 68307764 254326602 186018838
Prior authorization multiplier 0.5 (tight) 1.25 (loose) 80658591 201646479 120987887
Years 3-5 scenario decline continued growth 131422664 234317254 102894590
Price scenario announced $245 net central rebate 68307764 161317183 93009419
Uptake multiplier 0.75 1.25 120987887 201646479 80658591
Gross cost per prescription $1,164 $1,252 158358001 170258820 11900819
correlation gross_median gross_p05 gross_p95 net_median net_p05 net_p95 pmpm_median pmpm_p05 pmpm_p95 draws
common draw (perfect correlation between event times) 312461762 136151964 621475140 143594881 50333373 347264112 2.39 0.84 5.79 10000
independent event times 310412909 168476256 575405582 145407673 58055754 319919977 2.42 0.97 5.33 10000

Tornado chart of the five-year net budget impact of Medicaid coverage for 1 million enrollees, central 161.3 million dollars, with one bar per parameter: Coverage effect (95% CI); Rebate share; Prior authorization multiplier; Years 3-5 scenario; Price scenario; Uptake multiplier; Gross cost per prescription.

Tornado

Waterfall chart from gross cost per enrollee per month of 5.51 dollars, down by the rebate to a net 2.69 dollars, and to 1.14 dollars at the announced price.

Waterfall

Histogram of five-year net budget impact across 10,000 draws; median 145.4 million dollars, 90 percent interval 58.1 to 319.9 million.

PSA distribution

Value context

Trial weight loss next to net cost per user per year; context only, no cost-effectiveness claim.

Trial Arm Dose Weeks Weight change, % (95% CI) Medicaid gross reimbursement per prescription, covering states, 2025, USD Net cost per user per year, USD (4.3 fills, midpoint rebate; blended Wegovy and Zepbound) Net cost per member-year of continuous treatment, USD (12 fills, assumption) Citation DOI
STEP 1 semaglutide 2.4 mg once weekly (subcutaneous) 68 -14.9 (arm CI not in abstract) 1,303 2,511 6,943 Wilding JPH et al. Once-Weekly Semaglutide in Adults with O… 10.1056/NEJMoa2032183
SURMOUNT-1 tirzepatide 5 mg 5 mg once weekly (subcutaneous) 72 -15.0 (-15.9 to -14.2) 1,048 2,511 6,943 Jastreboff AM et al. Tirzepatide Once Weekly for the Treatm… 10.1056/NEJMoa2206038
SURMOUNT-1 tirzepatide 10 mg 10 mg once weekly 72 -19.5 (-20.4 to -18.5) 1,048 2,511 6,943 Jastreboff AM et al. Tirzepatide Once Weekly for the Treatm… 10.1056/NEJMoa2206038
SURMOUNT-1 tirzepatide 15 mg 15 mg once weekly 72 -20.9 (-21.8 to -19.9) 1,048 2,511 6,943 Jastreboff AM et al. Tirzepatide Once Weekly for the Treatm… 10.1056/NEJMoa2206038
SURMOUNT-5 tirzepatide maximum tolerated dose (10 mg or 15 mg) once weekly 72 -20.2 (-21.4 to -19.1) 1,048 2,511 6,943 Aronne LJ et al. Tirzepatide as Compared with Semaglutide f… 10.1056/NEJMoa2416394
SURMOUNT-5 semaglutide maximum tolerated dose (1.7 mg or 2.4 mg) once weekly 72 -13.7 (-14.9 to -12.6) 1,303 2,511 6,943 Aronne LJ et al. Tirzepatide as Compared with Semaglutide f… 10.1056/NEJMoa2416394
ATTAIN-1 orforglipron 6 mg 6 mg once daily (oral) 72 -7.5 (-8.2 to -6.8) not a Medicaid-covered obesity product in the SDUD window 2,511 6,943 Wharton S et al. Orforglipron, an Oral Small-Molecule GLP-1… 10.1056/NEJMoa2511774
ATTAIN-1 orforglipron 12 mg 12 mg once daily 72 -8.4 (-9.1 to -7.7) not a Medicaid-covered obesity product in the SDUD window 2,511 6,943 Wharton S et al. Orforglipron, an Oral Small-Molecule GLP-1… 10.1056/NEJMoa2511774
ATTAIN-1 orforglipron 36 mg 36 mg once daily 72 -11.2 (-12.0 to -10.4) not a Medicaid-covered obesity product in the SDUD window 2,511 6,943 Wharton S et al. Orforglipron, an Oral Small-Molecule GLP-1… 10.1056/NEJMoa2511774

Part of the project report; every number comes from analysis/outputs/key_numbers.csv. Public aggregate data; no company affiliation or endorsement.