There Is a Better Way to Help Patients Than PDABs and UPLs
The Ensuring Access through Collaborative Health (EACH) and Patient Inclusion Council (PIC) Coalition urges state lawmakers to rethink the creation of Prescription Drug Affordability Boards (PDABs) and implementation of upper payment limits (UPLs).
Colorado recently became the first PDAB in the nation to approve a UPL, capping reimbursement rates for Enbrel at the Medicare Maximum Fair Price (MFP). This decision risks increasing barriers for patients without lowering their out-of-pocket costs for medications.
UPLs Don’t Lower Patient Costs or Address Patient Needs
By design, UPLs cap spending for states and health plans, not patient out-of-pocket costs.
Our Patient Experience Survey found that:
- Patients facing out-of-pocket costs at all levels (from $10-250+) still described their drugs as unaffordable due to insurance barriers, low income, cumulative costs, and inability to access financial assistance.
- No individual drug emerged as singularly creating hardship; instead, affordability and access were more directly impacted by insurance coverage and personal life circumstances.
Simply put: a UPL doesn’t address the real drivers of patient hardship.
Risks to Access and Continuity of Care
UPLs create incentives for insurers and PBMs to respond with cost-cutting tactics, formulary reshuffling, new prior authorizations, step therapy, and non-medical switching.
Our survey shows:
- 75% of patients who skipped or stretched doses also reported at least one instance of care disruption due to insurance delays, not price.
- 100% of patients who stopped treatment for affordability reasons cited insurance rules, denials, step therapy, or loss of copay assistance.
Policies that overlook these realities risk worsening the very problems they were meant to solve.
Colorado PDAB: Next Steps Must Include Patient Protections
Now that Colorado has approved the first UPL, the state has a responsibility to closely monitor downstream impacts and adopt safeguards that protect patients. We urge:
- Transparent monitoring: Require data on insurer and PBM responses, including formulary placement, tiering, and utilization management changes.
- Legislative guardrails: Prohibit non-medical switching, new prior authorization hurdles, and adverse formulary shifts for drugs subject to a UPL.
- Patient engagement: Involve patient organizations in ongoing oversight to ensure real-world experiences drive corrective action if harms occur.
Without these measures, patients will bear the risks of a policy experiment that is untested and unproven.
A Better Path: Patient-Centered Reforms
States should prioritize reforms that patients say matter most:
- PBM accountability: End spread pricing, delink PBM compensation from drug costs, and require rebates to be passed directly to patients.
- Out-of-pocket caps & smoothing: Ensure costs are predictable and manageable year-round.
- Expand assistance programs: Protect and broaden access to financial support so patients are not left without lifelines when insurance rules change.
Conclusion
Colorado’s decision sets a precedent, but it should not be repeated. UPLs are unlikely to lower patient out-of-pocket costs and risk creating new barriers to care.
State legislatures have the power to do better by addressing the true drivers of unaffordability and ensuring patients remain at the center of every affordability policy.
EACH/PIC Coalition
Ensuring Access through Collaborative Health Coalition & Patient Inclusion Council