The EACH/PIC Coalition submitted letters to the Maryland PDAB in response to cost reviews for Dupixent and Skyrizi.
The letters stated:
As the board begins its cost review of Dupixent, we urge it to focus first on whether Maryland patients are experiencing affordability or access challenges, identify the specific factors driving those challenges, and ensure that any resulting policy recommendations are tailored to address them. A finding that a drug imposes costs on the health care system is not, on its own, evidence that the drug is unaffordable for patients or that an upper payment limit (UPL) will improve patient affordability.
We urge the board to focus on identifying and addressing patient concerns with prescription drugs. Our Patient Experience Survey found that 41% of respondents had paid multiple out-of-pocket amounts for the same drug over time, and more than half of those respondents reported that the same medication had been affordable at one point and unaffordable at another. Ninety percent of respondents who explained why their costs changed attributed those shifts to insurance-related factors. These findings demonstrate why a cost review must look beyond a drug’s price and determine what is actually driving affordability challenges for patients.
In evaluating patient affordability, the board should distinguish between affordability challenges driven by direct cost-sharing and access challenges driven by coverage denials, deductibles, utilization management, formulary restrictions, or limitations on financial assistance. Those experiences may all be reported as “unaffordability,” but they point to different underlying problems and require different policy responses.
Maryland’s framework allows the board to evaluate both UPL and non-UPL policy interventions as part of its affordability work. The board should use the Dupixent review not simply to determine whether an affordability challenge exists, but to identify its source and evaluate which available policy response is best suited to address it.
Any policy intervention resulting from the Dupixent review should be evaluated not only for its intended effect on costs, but also for its potential impact on patient access and continuity of care. Changes in payer incentives can affect formulary placement, utilization management, coverage criteria, and treatment availability. For patients who have already found a therapy that effectively manages their condition, even an unintended change in access can have significant consequences.
While UPLs are intended to address affordability, they also create new financial incentives for payers that could affect formulary placement, utilization management, or coverage of selected medications. The board should carefully evaluate these potential consequences before recommending a UPL, particularly when the affordability challenges identified through its review may be better addressed through other policy interventions.