ABSTRACT
Healthcare in the United States is mainly administered through private insurance or Managed Care Organizations (MCOs) and government-run Medicare and Medicaid bodies. Drug prices can be set without government restrictions in the US, although there are some post-launch limitations in pricing freedom for the government sector. Pricing decisions and discounts and rebates granted to selected customers can have implications for reimbursement rates for Medicare, Medicaid and other government agencies. The large majority of US citizens have health insurance that is sponsored by their employer and administered by a private insurer or MCO. Formulary negotiations between healthcare plans or Pharmacy Benefits Managers (PBMs) and pharmaceutical companies are confidential and discount and rebate terms are generally not known to the public. Prior Authorizations (PA) are simply used to verify that the use is within drug labeling. This may include verification of diagnosis and proof of prior treatments used. Contracting is usually attractive for MCOs when multiple drugs are available within the same drug class.
