The EACH/PIC Coalition submitted a group letter signed by 25 organizations opposing the creation of an upper payment limit for Cosentyx.
The letter stated:
“We support efforts to improve affordability and reduce patient hardship. However, our recent patient affordability research suggests that a UPL is unlikely to address the factors patients identify as driving affordability challenges and may create new risks to treatment access and continuity of care.”
“Recent findings from the EACH/PIC Patient Experience Survey 2.0 demonstrate that affordability is far more complex than the price of an individual medication. Patients consistently defined affordability as the ability to maintain access to treatment within their overall household budget, taking into account insurance coverage, cumulative healthcare costs, income, and changing life circumstances.”
“The board has stated that its UPL is intended to generate savings for patients. However, a UPL does not directly reduce patient cost-sharing obligations or guarantee lower out-of-pocket costs. Whether patients experience savings will depend largely on how insurers and pharmacy benefit managers respond following implementation.”
“Patients consistently reported that treatments are not interchangeable and described significant consequences when required to switch therapies for non-medical reasons after finding a treatment that worked for them.
“These concerns are particularly relevant because a UPL may prompt insurers and PBMs to modify coverage policies in ways that affect patient access. If insurers or PBMs respond to a UPL by implementing formulary changes, adverse tiering, expanded prior authorization requirements, step therapy protocols, or other utilization management tools, patients could face new barriers to accessing their prescribed treatment.”
“Affordability policies should not improve one metric while creating new access challenges for patients living with chronic and complex conditions.”
“Colorado is currently considering additional UPLs before its first approved UPL has taken effect and before any real-world evidence exists regarding its impact on patient affordability, access to care, utilization management practices, formulary design, or provider reimbursement.”
“This uncertainty is compounded by limitations in the board’s monitoring framework. Under the board’s current framework, reporting will occur approximately one year after implementation, meaning patients could experience unintended consequences long before those impacts are identified and addressed. By the time data is collected, reviewed, and acted upon, patients could already have experienced treatment disruptions, increased administrative burdens, or changes in coverage that affect access to care.”
“Before expanding the use of UPLs to additional therapies, the board should first evaluate whether its initial UPL achieves its stated objectives, whether savings are reaching patients, and whether unintended access barriers emerge following implementation. At a minimum, future evaluations should include direct patient engagement, patient-reported affordability and access measures, and independent verification of reported savings.”