Following the decision of the Colorado PDAB to implement an upper payment limit (UPL) for the drug Enbrel, the EACH/PIC Coalition sent a letter to members of the Colorado Legislature serving on the House and Senate Committees on Health and Human Services. The letter warns against potential unintended consequences of the UPL on Colorado patients and urges for transparent monitoring and legislative guardrails to protect patients.
The letter states:
While we all share the goal of lowering patient costs for prescription drugs, we have long opposed PDAB and UPL models because they remain untested, unproven, and risk creating new barriers between patients and their medically necessary treatments.
Having established the PDAB and empowered it to set UPLs, Colorado legislators have a duty to ensure this authority is exercised responsibly and does not put patients in harm’s way. We urge you to ensure this experiment does not cause harm by passing measures to increase oversight and implement proactive patient protections.
Transparent Monitoring
Colorado legislators should require the PDAB to establish a robust monitoring program and grant any additional authority necessary to do so. At a minimum, monitoring should:
- Collect and publish data from insurers and pharmacy benefit managers (PBMs) on formulary placement, tiering, utilization management, and cost-sharing changes for UPL drugs.
- Track provider-level impacts, including reimbursement rates, prescribing patterns, and patient access in physician offices, infusion centers, and pharmacies.
- Include independent evaluation to determine whether payer savings are being passed on to patients or retained by insurers and PBMs.
Legislative Guardrails
At the same time, legislators should establish statutory protections to ensure UPLs do not create new barriers to care. Guardrails should include:
- Prohibiting non-medical switching of patients stabilized on a therapy.
- Protecting provider reimbursement so physicians, clinics, and pharmacies are not forced to absorb unsustainable financial losses.
- Banning new prior authorization or step therapy hurdles on UPL-affected drugs.
- Preventing adverse formulary shifts that push UPL drugs to higher tiers or exclude copay assistance.