Comment by dbg31415

It’s not like you can just switch insurance companies in the US. Most people have healthcare coverage through their employer.

Americans get no drugs covered--at all--unless you're over 65, have insurance through your employer, or pay thousands for insurance yourself (and often thousands more to meet your out-of-pocket deductible each year).

I would take the default of "some" coverage over "no" coverage any day.

I don't take it but did look into it.

If anything getting it for diabetes got harder now.

Canadian employers sunlife insurance.

If you were prescribed it before the influx(not specific date) it was covered for diabetic purposes and still covered.

Now if you want to apply sunlife says NO, but you can get your doctor to send us these forms with additional info about the diabetes diagnosis and need and may be covered.

On the flip side theres a local diabetic that has been getting multiple high dosage units covered, but doesn't actually need them or take them

Flips them for $200 cad each to people looki g for weightloss.... (230-280cad in a pharmacy with prescription no insurance)

Only for diabetes. Wegovy is authorized for weight loss. There are other GLP agonists that are also authorized for diabetes. I'm not sure if there are other formulations for weight loss.

The US does allow for "off-label" prescriptions. The question then is : will your insurance pay for it. In my case, even though I am diabetic, they wouldn't cover Ozempic, or, apparently even Trulicity, which is just absurd (or Rybelsus which is the oral form of Semaglutide which they DID cover for a full year before putting me on Ozempic for like 2 months, and then denying (after the "new formularies" are approved and I get to be forced and switch to a med they still claimed to cover but not, apparently - I'm assuming they want me to appeal and give a whole run around on that.

But yeah... Technically it's for Diabetes only, but if you have good insurance, they'll probably hand out for any reason (see: "Hottest Celebrity Weight Loss Drug" for example; maybe that's changed now that Wegovy is released/authorized for weight loss)

Your boss is presumably a high-value employee at a prosperous company. They will have good health insurance, but that’s not the norm for most people.

When I worked for Facebook in the US, it was conspicuous how doctors would run extra tests on me because the health insurance was paying for everything and anything. That’s not balanced either because less fortunate people pay for that in their insurance premiums.

It is just them. The way insurance works in the US is that insurers negotiate with pharmaceutical companies to get steep rebates so that they are paying far less for the drug than its list price, typically much closer to what you might pay in other countries. If they can't come to an agreement, they won't cover the drug. Sounds reasonable. But in practice, what happens is that if a pharmaceutical company simply cuts the list price to what the rebate would be anyway, the insurance company ends up dropping them from coverage. This seems counter-intuitive, but it happens for two reasons.

First, the middle-men who negotiate and develop the formularies for insurance companies, called pharmacy benefit managers, get a cut of the reduced cost. So they make more money from a drug being $1000 and rebated to $100 than they would from the drug just being $100 all along. The pharma company makes the same amount per unit, $100, but they are much more likely to get onto an insurance plan if they go through the sham of marking it up to $1000 and then cutting it down.

Secondly, extremely inflated list prices that get rebated down simply mean that it becomes that much more critical for patients to pay for an insurance plan, because it is increasingly untenable to be without one.

These "negotiations" that PBMs do have been closely guarded "trade-secrets" but pharma companies have in recent congressional hearings have essentially said this is the situation. This seems to be supported by the fact that in their financial reports for products like insulin, the actual profit per unit has largely kept pace with inflation over the last few decades, despite the listed price of insulin skyrocketing during the same timeframe.

This is pretty much entirely the result of there not being a non-profit seeking government provided insurance option available to all in the US. If there is a reasonable alternative to private insurance that isn't engaging in the insurance cartel, no one is forced to use private insurance and the private insurers are actually forced to compete in a market. Completely socialized medicine isn't required, we simply need a Medicare-for-all option available to destroy the anti-competitive behavior that currently exists in the US insurance market.

I mean yes but there is no solution to that problem, but there are many tried and true solutions to the other problem, so this just reads as deflection

Doctor's office won't make money from prescriptions for a drug, and the pharmaceutical company will sell their drug to whoever will buy it. Both those entities also exist in non-US medication transactions as well, so I'm not sure it's relevant. The point is that the insurer and the employer are two extra middlemen.

At least the set of approved drugs is known. In the US you don’t know until you try to fill the orecription, then it becomes a 4-way game of telephone (patient, MD, pharmacist, and insurance) with each trying to outlast the other.

That's wild; HIPAA mainly exists to protect medical data from employers (among other threat actors) in the first place

Insurance companies are absolutely covered by HIPAA. If it’s true that the insurance company (and not some third party service or app) shared the information directly with HR this is definitely a violation.

https://www.hhs.gov/hipaa/for-professionals/covered-entities...

What’s the I stand for in HIPAA?