The EACH/PIC Coalition submitted a comment letter to the CO PDAB for consideration during the rulemaking hearing to establish an upper payment limit for Enbrel.
The letter states:
“Proceeding with UPL hearings based on determinations made using inaccurate or incomplete data would be premature and potentially harmful. We urge the board to take the time necessary to re-evaluate the affordability reviews for Enbrel, Stelara, and Cosentyx to ensure that decisions are informed by accurate evidence and reflect the true experiences and needs of patients.
“We remain skeptical that the implementation of UPLs will actually lower costs for patients. A UPL is a ceiling on what insurers or the state may pay for a medication, not a cap on the amount a patient must pay at the pharmacy counter. The board does not have the authority to set limits on patient out-of-pocket costs, nor can it require insurers to adjust cost-sharing arrangements in line with a UPL. Without a mechanism to ensure that savings are passed along to patients, UPLs may offer little to no benefit to those who rely on the medications under review.
“Moreover, we are concerned that UPLs could further complicate the already fragmented drug coverage landscape. Setting a UPL on a specific medication could trigger changes by insurers—such as reshuffling preferred drug lists, instituting new prior authorization requirements, or requiring patients to try other drugs first—all of which may delay or restrict access to the treatments patients need. Providers may also be impacted, as lower reimbursement rates could limit their ability to purchase, administer, or dispense certain medications. These disruptions can lead to care delays, increased administrative burdens, and diminished health outcomes.
“Importantly, we do not yet know how insurers, manufacturers, or pharmacies will respond to a state-specific pricing model. Limiting reimbursement for certain products could result in reduced availability in states where UPLs are implemented, further limiting access and choice for patients.”