re: The Prior Authorization Process for Medicine

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eah it's entirely a plan thing. One PBM I had required a PA for Adderall, but also required that I get brand... it made no sense. The labor costs to do that PA were more expensive than paying out at 100% for the very very short duration I even had that plan

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It, sadly, makes perfect sense for a few reasons:
1) the drug companies don’t pay what you would pay for branded drugs. They’re allowed to make deals to get branded drugs cheap to not allow the generics on formulary (or in other words, two competing drug companies exist, one pays a huge amount to the PBM to be the exclusive med on the formulary and the competitor not being covered. The company now has the money with which to buy the drug for cheap). I have a friend who used to work in the lab that made a specific drug. An Indian company infringed on their patent. There was a settlement. One of the final terms of the settlement was for the Indian company to be allowed to sell the drug, but it required them to do so at a much HIGHER price than originally intended (roughly the price of the branded medication that they conveniently quit producing because they were getting paid by the generic maker who was now making huge margins)


2) the process isn’t about anything but finding new reasons to deny coverage. They don’t care what you need or what’s indicated. They care about 1 in every 20-30 getting set aside and a different, more favorable (to them) medication being prescribed.


Here’s an old article that gives decent overview into a handful of the practices. Here is a short, funny video with an overview of some of the practices.