If you remove a bunch of constraints, you can imagine governments paying for country-wide license to the patent, and then individuals just pay enough to cover manufacturing and delivery. I'm not sure if there was any payment that went along with granting India the $1000 price. I know India carries a big-stick of "invalidating" the patent. Sure, they could have just taken the IP for themselves, which basically means Americans just bare a larger share of the overall cost. The fact is that this drug is tremendously valuable for India, so I'm glad they were able to come to some pricing agreement.
Selling those drugs back into the US market clearly goes against the pricing agreement. Based on what I read in those articles about Paul Le Roux, these online drug outfits have way more volume than you might expect, and they apparently can run for a long time before being shut down. This is partly a submarine ad in that sense, even naming sources. You also might expect customs to intercept these packages, but when Le Roux can share the same FedEx account number across all their pill shipments, clearly inspection is expected to be lax. So the result is these pills could actually be pouring back into the country, and hiding within the inventory being sold for consumption actually inside India. It seems like Gilead revenue is strong for now, I don't know if they consider this to be a significant risk.
In some cases insurance will not cover if you are not showing symptoms. But if they do cover it, you will be on the hook for just the out-of-pocket maximum for that year. Any other health care you receive that year will be free, so that could also help justify the cost. But in this case the insurance company didn't want to cover it anyway, so the patient was forced to pursue a gray market purchase. I'm pretty sure Gilead is pushing hard for insurance companies to cover anyone with detectable disease regardless of symptoms, and ultimately that's what we want. There's a huge population that avoided the prior treatments, but would jump on this in a second.
Everyone who has HepC should get this drug. But if we can't afford to cure everyone today, how do prioritize access? And how do you limit access to an FDA approved drug for a diagnosed illness anyway, when the alternatives are more expensive and less effective? Well I guess in some places, like the NY AG is requiring coverage for commercial insurance plans. NYT reports that Medicaid is still denying coverage until the disease has advanced.
We want people to pay the "right" price for this drug, really a miracle cure which is lowering the cost of treatment actually. So how do you price it? The price to the insured patient today will vary based on the financial means of the patient. The revenue to Gilead is negotiated with insurance companies / benefit management companies, and is far below the sticker price.