Insurance denied the claim.
They "applied a coupon" and the price magically became $35.
In this one transaction there's multiple layers of corruption most likely starting with the prescribing doctor.
I remember reading several years ago reports that drug companies were favoring coupon distribution to doctors according to how often doctors prescribed the issuer's name-brand drugs instead of generics. That is, a doctor who prescribed a designer expensive drug, Foo, more often might get more coupons for name-brand but boring drug, Bar, for distribution to the doctor's indigent patients. I don't remember, however, if or which reforms were enacted as a result. Also, I'm not sure if it was nearly as big of an issue as actual kick-backs in the form of vacations, etc, which (AFAIU) were made illegal years ago. The opacity and overall baroqueness of the coupon system is precisely why there's not much opportunity for doctors to personally benefit from the scheme, yet why it works well as a tool for pharmaceutical companies to maximize profits while staving off political reforms.
Those coupon programs aren’t used for indigent patients since they reduce the co-pay/co-insurance the patient has.
Some not so great insurance plans will pay 90% of drug costs. Great when the drug is $300 per month. Not great when it’s $3,000. So manufacturers will directly pay an additional portion to cap the patients part at say $50 per month.
Your post lacks information such as whether or not the specialty medicine would’ve been approved with the proper paperwork from the doctor, but what likely happened is that someone at the pharmacy put in the effort to find a manufacturer coupon for the medicine for you.
Interestingly the pharmacy doing that is generally forbidden in agreements with the insurance companies. That’s corruption imo.
The insurance PBMs forcing you to use their designated specialty pharmacies is part of the massive healthcare consolidation over the last couple of decades and it’s full of corruption as well.
> Have curious conversation; don't cross-examine.
> Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith.
This was all explained to me when we had to switch plans, ended up with Kaiser for a while, and needed to renew blood pressure meds for my wife.
She was in good control, no side effects, on meds for a decade. Those were not on the list. Rather than prescribe off list, that doctor increased her risk to benefit Kaiser, not her. And this was even made clear at the time! (maddening) Just to be ultra clear, it was that doctors "opinion" the various meds were all equivalent.
For a lot of reasons, none of which are medical, we went with it, and sure enough, she was not in good control, and had side effects.
Went back, got the meds that worked prescribed, (which cost me visit co-pays and some non trivial time and effort to basically demand the medication needed and proven) and found ourselves in the same "coupon" scenario above. Base cost of the medication was quite expensive, and a "coupon" was found to bring it roughly in line with the "on list" meds tried earlier. Of course, that all had to be done at another, outside pharmacy, due to the Kaiser one not carrying what they consider special order meds. That isn't a super big deal, but the whole mess involves bulk buying to gain price advantages, and the real worry point is cost being primary, with medical being secondary.
The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health.
In my case, the pharmacy was Walgreens and yes they signed me up for some plan or other, GoodRX or the like, handed me a card and said I needed to use it to get the much better price. Was on the order of a few hundred dollars being discounted to a few tens of dollars...
Have had similar experiences at CVS, Bi-Mart, Safeway... Indie pharmacies, usually niche places that offer things like compounding, are particularly good at this sort of thing and it's one of the ways they attract and keep patients. I used a good one for years, until I moved. Miss those people. They would do that automatically for anyone struggling with med costs of any kind.
The flip side of this is the "pharmaceutical representative" entire job description. Basically, your doctor has a wide range of words they use to describe how to treat you. Some of them wind up with the insurance company paying $15 for generic medication, while others wind up doing something like spending $400 on something under patent protection. Pharma's reps jobs are to talk to physicians and educate/convince them to use the expensive words instead of the cheap words out of force of habit.
Anyhow, that's why HMOs and insurers have approved medication lists - to push back against doctors writing down a $400 word instead of a $15 because a pharma representative said that FooBar XR treats Baz syndrome and the doctor wrote that down instead of the generic BarFoo.
Count me as a strong supporter for reform. I quite frankly, hate it.
These companies are so massive and complicated in their roles and processes you and I cannot easily figure out specific actionable blame onto the specific administrators and processes involved.
Blame those who made the system. Doctors are forced to work 80 hour weeks for not as much pay as you're thinking. Clinical Doctors don't have the power to better their own conditions, how are do they have the huge power to reform the regulatory issue of medicine pricing?
Start blaming the source of the problem - the business executives whom made these decisions.
Insurance companies are thrilled with high prices because they reinforce the idea that medical insurance is critical infrastructure. Liberal politicians love taking credit for throwing money at the problem they helped codify into law, and conservative politicians love being able to decry out-of-control, cradle-to-grave socialism at every campaign stop.
So yeah there are multiple layers of corruption there.
This makes NFTs and drug dealers look honest. Oh, wait, they kinfld of are drug dealers.