Why US brand drugs are ~4×
In the US, nobody bargains as a country. Each PBM takes a rebate off a high list. Until the Inflation Reduction Act, Medicare was not allowed to negotiate. Other countries set one price. The manufacturer takes it or does not sell.
PBM list + 340B spread
How it works
Until the Inflation Reduction Act, Medicare was forbidden to negotiate. Private PBMs take rebates off a list that never had a national ceiling. 340B hospitals buy cheap and bill the job plan near ASP-plus. Site of care is a second markup on the same vial.
Why it holds
The US is the residual profit pool for originator drugs. List stays high because nobody bargains as a country. Even after confidential rebates, net brands stay more than 3× other OECD. Unbranded generics go the other way — the US is often cheaper. The 5% buy the brands.
The invoices
See RAND drugs, 340B. 30-day list prices: CMS 2023, Inflation Reduction Act round 1.
Twenty brands — US sticker vs OECD
Ranked by the US number. 30-day list is CMS 2023 (Inflation Reduction Act round 1). Infusion doses are our hospital commercial bill. OECD column is US list ÷ 4.22 (RAND brand originators). Gross list, not rebates. Even after a US rebate haircut, RAND says brands stay more than 3×.