The EACH/PIC Coalition submitted comments to the Colorado PDAB in advance of their third rulemaking hearing to implement an upper payment limit for Enbrel. The letter highlights concerns with the impact of a UPL on patients, the need for patient protections, and urges the board to put review provisions in place before setting a UPL.
The letter stated:
“We remain unconvinced that a UPL will result in meaningful savings for patients, including the uninsured, who have been cited in board discussions as a key beneficiary. By design, a UPL caps what insurers and the state may pay for a drug, not what patients pay. The board does not have the authority to reduce out-of-pocket (OOP) costs, which means patients could see little to no change in what they are charged.”
“UPLs remain untested and unproven. No state has yet demonstrated that they can lower patient costs without creating harmful downstream effects. What is clear, however, is that insurers and PBMs will play a decisive role in how a UPL is implemented, and these stakeholders have been largely absent from the visible portion of the UPL consideration process in Colorado.”
“Patients cannot accept “we don’t know” as an adequate answer from officials when access to life-sustaining medications hangs in the balance. At a minimum, due diligence requires the board to demand evidence from payers and PBMs on formulary placement, tiering, and utilization management changes, and integrate this information into a transparent monitoring process before any UPL is finalized.”
“Monitoring the effects of a UPL after implementation is still ‘flying the plane while building it,’ which cannot be a substitute for proactive protections. Patients will bear the immediate consequences of insurer and PBM responses, while any corrective action from the board could take months or years.“