You're right about Medicaid paying the least and having very favorable pricing in general. Also repayment rates vary wildly by state, etc. But the baseline rate

You're right about Medicaid paying the least and having very favorable pricing in general. Also repayment rates vary wildly by state, etc. But the baseline rates are still based off the reported average price. Drug manufacturers know that the government will always pay some fraction of sticker price, regardless of the volume the average price is based on. CMS can't negotiate in the face of these dramatic price hikes. And yeah, it's price by fiat, through the market. Welcome to government contracts - plenty of people have become very rich in this space, and I have no sympathy to those that complain about their slim profit margins on incredibly high volume transactions. It's a big job. Get rich doing it, or get out of the way for someone who will, because it's got to get done.