The EACH/PIC Coalition submitted comments to the Colorado PDAB in advance of their second rulemaking hearing to implement an upper payment limit for Enbrel. The letter, signed by 23 organizations, urged the board not to implement a UPL, based on concerns about the potential impact of a UPL on patient access and flaws in the methodology for cost reviews.
The comments stated:
“On behalf of the patients we represent, the undersigned groups urge the Colorado PDAB to decline to implement a UPL on Enbrel in the state. Broadly, we are concerned that a UPL will not result in any lowered costs for patients but could put their access to Enbrel or other drugs in the therapeutic class at risk in the future.“
“Assuming that UPLs directly translate to lowered costs for patients ignores the complicated nature of our healthcare system. Establishing a UPL will place 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.”
“Setting a UPL for a specific medication may prompt insurers to make changes—such as reshuffling formularies, adding prior authorization requirements, or implementing step therapy protocols. Each of these measures can delay or restrict access to needed treatments. … These disruptions can result in treatment delays, increased administrative burden, and poorer health outcomes for patients.”
“As a measure of basic due diligence, we urge the board to obtain concrete information from all sectors of the healthcare marketplace—manufacturers, insurers, PBMs, and providers—regarding how they will respond to the implementation of a UPL. The decisions of any one of these actors could influence whether patients continue to have access to critical medications. If even one stakeholder responds by limiting availability or access due to the constraints of a UPL, the result could be disruptions to continuity of care and increased burdens on patients and providers alike.”