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Don’t forget that pharmacy rebates are included in formulary decisions. Rebates are sometimes a substantial portion of the cost that consumers pay for their medication’s, and our returned directly back to the HEALTH INSURANCE or PBM, those rebates never make it back to the members. So I remember paying $1000 for a drug that has a $300 rebate never gets that money back. The health insurance company gets the money as profit.

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Of course.

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It would be interesting to have a comparison about how formularies work in different countries. For example, in Germany I dont think this is much of a problem.

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A brief review of this article suggests two major differences: 1) the insurers negotiate all of their formularies and pricing in a cartel the GRK-SV. 2) The insurers don't own any pharmacies. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/drug-price-moderation-germany-lessons-us-reform-efforts

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The original sin of US healthcare to me is that people who manage other people's money (PBMs and insurers) get to own and also BE the recipients of that money (providers and pharmacies). The temptations to screw everything up under such a system are myriad.

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