Novartis doesn’t want Gilenya to go generic. It occurred to me on the drive home that this is really just a pissy little fight between Novartis, the mail order pharmacies, and Blue Cross Blue Shield. I have several, several, several questions. See if your plan participates in SaveOnSP through Express Scripts. Why is an MS patient like myself with cognitive impairment given such a complicated mess of paperwork to analyze? Why is the data I need about my own insurance plan not available on the BCBS website? Why isn’t there ANYBODY in the system that can look out for chronically ill patients?.I get the idea of what you’re saying, but functionally, I’m not sure how that would be implemented. I’m not sure what medically necessary means in this context vs industry terms.But if you ask a doctor (or an MS patient like myself) Gilenya delays progression. Why don’t they declare Gilenya a medically necessary drug? Part of the reason they’re allowed to do this is that drugs like Gilenya are officially not medically necessary to sustain life. ![]() That being said, is the generic a covered medication on your formulary? Would that be a cheaper alternative without the Gilenya Go? My gut reaction is that in order to get the medication covered on the Gilenya Go program, it cannot be generic.Why wouldn’t BCBS allow me to take a generic?.They will charge the pharmacy whatever they can for the drugs they produce. Finally, there’s the drug manufacturer.ALL of those means must be approved by the client. The PBM (Express Scripts, for example) acts as a middle man to negotiate the price that they will pay the pharmacy for medications (lowering that submitted price) and the price that the client will pay to cover that medication through several means (contract pricing, formulary restrictions, step therapy, Prior Authorizations).the one who picks which insurance company they offer plans through) wants to pay as little as possible for the medication that you take and thus restrict what you can get (i.e. The “client” (typically an employer, i.e.They typically submit costs much higher than market value to get there. The pharmacy wants to get as much money as they can for the medication they dispense. There are several factors at work. ![]() ![]()
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