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There are 2 other players adding to the 3 players we already mentioned:
Insurance companies are using Pharmacy Benefit managers to negotiate with manufacturers, so they increase the prices of medications.
Why would insurance companies increase the price of medicines they are supposed to cover from their pockets? Doesn’t make sense. But here is where the shady practices arise.
This increase in price by manufacturer returns to insurance companies through PBM in the form of rebates.
Instead of 100$ drug with 50/50 copay now insurance companies offer to cover 95% of 1000$ drug. The insurance company pays 950$, gets 900 as a rebate from the manufacturer. And the customer pays 50$ as a copay.
This allows certain drugs to climb up the “formulary” rating, making them a more attractive prescription option because the copay percentage is only 5% instead of 50%.