I think the other issue is that generics have such bad margins that it's hard to convince anyone to manufacturer them in the best of cases, so if anything happens to make a generic too hard to sell they'll just give up.

Combining that with PBMs being allowed to choose a preferred manufacturer for a generic or even preferring the (more expensive for the patient) brand, and refusing to offer the same coverage for a generic and you get less access to generics than there should be.

Honestly, PBMs should have to contribute at least the same amount of money to any version of a drug. If it's genuinely more expensive for them, the patient would still have to pay more. If it's not, it's none of their business.

Can you explain your last thought? I dont quite follow.

I do think a lot of the rot is in the PBM layer, and the country would benefit from an attempt to eliminate it, reduce their influence, and move away from the formulary.

Insurance should dictate what is covered, NDC exclusions should be banned, and rebates should be discouraged.

Ideally manufacturers sell for a list price, and insurance decides what is an acceptable balance of cost to subscriber satisfaction.

PBMs would go back to handling the papwerwork, or better yet be replaced by an open standard protocol