VanRx_Mike said:

The mechanism and the magnitude are separate questions.

Right, and the exception is worth naming rather than left implied, because the exception is where people get into trouble.

Worth separating that from cost and coverage, which this thread keeps folding into the same question. They behave differently and the advice does not transfer.

AttorneyGrant said:

Agreed, and coverage criteria are plan-specific rather than insurer-specific.

That reframing is the part I needed. Sending this to two other people who asked me the same thing last week.

VanRx_Mike said:

The mechanism and the magnitude are separate questions.

Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.

Worth separating that from cost and coverage, which this thread keeps folding into the same question. They behave differently and the advice does not transfer.

One concrete data point for the thread. If you are comparing against somebody else’s result, check that you are comparing the same measurement taken the same way. Most of the apparent contradictions in these threads dissolve at that step.

Moderator note: reminder that nothing in this thread is medical advice, and that clinical claims need a source. No action needed from anybody.