When Jayant Mishra was diagnosed with psoriatic arthritis last year, the California resident understood he’d likely need lifelong treatment to manage the autoimmune disease.
After he was prescribed Otezla, a brand-name drug commonly used to control inflammation linked to the condition, Mishra says his rheumatologist helped enroll him in a manufacturer co-pay assistance program designed to shield patients from the medication’s steep price tag, which can run about $5,000 for a month’s supply.
Initially, everything appeared to work as promised. His insurance authorized coverage, the co-pay card was approved for nearly $9,500 annnually and his first prescription refill came with no out-of-pocket expenses.
“I was happy when I got the message,” he told The Washington Post, adding that his doctor had reassured him the co-pay card was expected to cover the medication (1).
But just weeks later, Mishra was billed $441.02 for his second refill and was told his co-pay card had been depleted.
Insurance records showed Mishra’s insurer covered only a small portion of Otezla’s roughly $5,250 monthly list price, paying just over $300 for a 30-day supply. Most of the remaining cost was covered by a manufacturer-funded co-pay assistance program he had enrolled in.
Health policy experts say situations like this reflect broader tensions in the U.S. prescription drug system. Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies pharmaceutical pricing, has described co-pay assistance programs as part of an ongoing tug-of-war between drug manufacturers, which set high list prices, and insurers trying to limit how much they pay for expensive medications.
Insurers have increasingly adopted co-pay accumulator and maximizer programs, which determine how manufacturer assistance is applied to prescription costs. Under these policies, assistance may lower what a patient pays at the pharmacy counter but often does not count toward their deductible or annual out-of-pocket maximum, allowing the funds to be used up quickly.
The dynamic reflects the reality of the U.S. drug market, where patients pay far more for medications than those in other developed countries. In 2022, prescription drug prices in the United States were about 2.8 times higher than prices in comparable nations (2).
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The companies involved offered differing explanations for how the costs were applied.
Caroline Landree, a spokesperson for UnitedHealthcare, said co-pay cards are arrangements between patients and pharmacies that operate outside of insurance coverage. Amgen, the drug’s manufacturer, pointed instead to health plan design.
“Co-pay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine,” spokesperson Elissa Snook said in an email statement to The Washington Post.
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Many Americans cannot afford the list price of brand-name prescription drugs. U.S. households carry at least $220 billion in medical debt, with health care costs leaving millions of people owing thousands of dollars (3).
Facing uncertainty about how much his medication would cost, Mishra said he began stretching his prescription supply by skipping doses and cutting pills in half while waiting for a new manufacturer’s co-pay card to reset in January. As he reduced his treatment, many of his symptoms returned.
According to the Centers for Disease Control and Prevention, the high cost of prescription drugs has led more than 9 million adults between the ages of 18 and 64 to skip doses, take smaller amounts or delay refilling medications (4).
Even after receiving a new co-pay card worth $9,450, Mishra said the assistance still did not cover his treatment. He paid additional costs from his health savings account to meet his $5,000 deductible, including a $550 charge in February. When he contacted his insurer about the next refill, he said he was told he could owe roughly $4,450 for a single month’s supply before reaching his out-of-pocket maximum.
Manufacturer-funded co-pay programs can help patients afford medications in the short term, but critics say they may also steer patients toward expensive brand-name drugs that insurers only partially cover. Federal rules also prohibit Medicare and Medicaid beneficiaries from using these programs, which regulators say can contribute to higher overall drug spending.
Policymakers have increasingly tried to address rising drug costs. A provision in the 2022 Inflation Reduction Act allows Medicare to negotiate prices for certain medications for the first time, though the policy largely applies to seniors and does not directly affect most privately insured patients like Mishra (5).
Consumers facing high prescription costs still have a few ways to lower what they pay.
According to Consumer Reports, one of the most important steps is talking with a doctor about whether lower-cost alternatives or generic medications could work, since different drugs used to treat the same condition may be covered more generously by insurance (6).
Patients can also look beyond their insurance plan by using pharmacy discount tools and savings programs, such as coupon platforms like GoodRx. They can also use low-cost generic programs offered by retailers like Walmart and Walgreens, which can sometimes significantly reduce the price of common medications.
It can also help to think about prescriptions when choosing a health plan during open enrollment. Some plans may offer lower co-pays for certain medications but come with higher monthly premiums. Caroline Landree, a spokesperson for UnitedHealthcare, said Mishra could have selected a 2026 plan that would cover Otezla for a $100 monthly co-pay, though it would have required paying more each month for coverage.
“Personally, I’m not in financial distress. I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”
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Washington Post (1); Assistant Secretary for Planning and Evaluation (2); Health System Tracker (3); Health (4); KFF (5); Consumer Reports (6).
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