The vote was four years in the making, had already survived one legal challenge<\/a> and represented a major victory for allies of Gov. Jared Polis\u2019 approach to reducing health care costs through stronger regulation.<\/p>\n \u201cThis groundbreaking upper payment limit on Enbrel has the potential to save $32 million from drug spending,\u201d Sophia Hennessy, the lead policy research coordinator for the Colorado Consumer Health Initiative, said in a statement. \u201cWe\u2019re thrilled with the board\u2019s decision today that helps ensure more patients can afford their vital medications.\u201d<\/p>\n But whether those promises will hold \u2014 whether patients will, in fact, save money or whether the relatively small number of Coloradans who take Enbrel will be able to continue to get it \u2014 is uncertain.<\/p>\n The pharmaceutical world is a deeply complicated place<\/a>. And it is filled with intricately intertwined and sometimes competing pieces: manufacturers and distributors and pharmacy benefit managers and insurers and pharmacies, each with their own business models and financial incentives.<\/p>\n The upper payment limit, also called a UPL, applies only to the very end of that chain. But it has the potential to pulse throughout it and, opponents warn, create whiplash.<\/p>\n In debates at the drug affordability board over the past four years, various groups have argued that setting upper payment limits could cause drug companies to stop offering their drugs in Colorado, stop pharmacies from buying the drugs to sell to patients, or stop insurance companies from covering the drugs.<\/p>\n \u201cThe board has heard, but so far failed to heed, repeated warnings from patients, patient organizations, hospitals, pharmacies, and providers of potential unintended consequences of implementing a UPL in Colorado,\u201d one coalition of patient advocacy groups wrote in a letter<\/a> last month specifically about Enbrel. \u201cPatients must not bear the burden of policies that are untested, inadequately monitored, and unlikely to address the affordability barriers they actually face.\u201d<\/p>\n The long road to a UPL<\/p>\n Colorado lawmakers created the drug affordability board in 2021 and gave it a unique power to set price limits on drugs. But it can only do so after a methodical process involving months or more of data analysis, surveys, public comment, rulemaking hearings and a series of votes.<\/p>\n The board voted more than a year ago<\/a> to declare Enbrel unaffordable, triggering the process to set a UPL.<\/p>\n About 2,500 people in Colorado take Enbrel, according to the drug board\u2019s affordability report<\/a>. Roughly 60% of those people are privately insured, meaning they share in paying the costs of the drug, which in 2023 was nearly $58,000 per year<\/a> on average per patient. Of that, insurers picked up about $53,000 per year on average, while patients each paid a little over $4,600 on average, not including their insurance premiums.<\/p>\n In setting the UPL, the drug board looked to Medicare\u2019s new \u201cmaximum fair price\u201d<\/a> for certain medications, and then rounded up to the nearest hundred to create some regulatory wiggle room. That put the UPL at $600 for a standard weekly adult dose of 50 milligrams, which comes out to about $31,000 per year.<\/p>\n \u201cThis is a great victory for patients in Colorado, because what good are medications to patients if we can\u2019t afford to access them?\u201d Laura Packard, the founder of the national advocacy group Voices of Health Care Action, said in a statement.<\/p>\n In its survey of Enbrel patients, the drug board found that 71% said the price of the drug made it difficult to access. But that survey received only 38 responses<\/a>, highlighting the challenge the board, also known as the PDAB, had in understanding patients\u2019 real world experiences beyond the data.<\/p>\n No Colorado patients taking Enbrel spoke at last week\u2019s final rulemaking hearing where the UPL was set. A handful of patients submitted letters to the board throughout the process.<\/p>\n \u201cNeither the board nor any of its experts can say unequivocally that fixing the price would lead to reduced out of pocket costs for individual patients,\u201d one Colorado woman who said she uses Enbrel wrote in a letter last year<\/a>. \u201cThat is at best curious and at worst bizarre.\u201d<\/p>\n The concerns over whether a UPL will help patients focus mostly on how the health care system will react to it.<\/p>\n The board has made clear it wants any savings passed onto patients<\/a>. But opponents question whether that will happen \u2014 or whether patients will continue paying the same copays and deductibles they do now.<\/p>\n Kevin McFatridge, the executive director of the insurer trade group Colorado Association of Health Plans, wrote in a letter to the board<\/a> that the UPL may cause insurers to change their drug formularies and tiering levels or to use \u201cutilization management tools\u201d \u2014 often a euphemism for care restrictions.<\/p>\n One speaker at last week\u2019s meeting warned that a lower price for Enbrel could lead to lower kickbacks from manufacturers to pharmacy benefit managers<\/a>, which might cause those middlemen to change their policies on Enbrel.<\/p>\n \u201cThe PBM issue you raise is just incredibly frustrating for all of us,\u201d Mizner responded.<\/p>\n Another speaker warned of the risk of what is known as \u201cnon-medical switching,\u201d which is when an insurer pushes a patient onto a different drug for economic reasons, not health reasons.<\/p>\n \u201cThere\u2019s just a real ingrained fear because I\u2019m always wondering if the insurance company is going to come back to me and say, \u2018Well, this is less expensive for us, so you have to be on this,\u2019\u201d the speaker, a woman from St. Louis named Tiffany Westrich-Robertson who is the founder of a patient advocacy group called the EACH\/PIC Coalition<\/a>, which fights drug affordability boards across the country, said.<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/10\/IMG_2560.jpeg\")
Democratic Colorado state Rep. Yadira Caraveo, a co-sponsor of legislation to create a prescription drug affordability board, speaks at a rally in support of the bill on the steps of the Colorado Capitol on May 19, 2021. (MARKIAN HAWRYLUK \/ KHN)<\/p>\n![\"Pills](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2025\/10\/AP18040607756340.jpg\")
In this Friday, July 8, 2016, file photo, a pharmacy technician fills a prescription at a pharmacy, in Sacramento, Calif. (AP Photo\/Rich Pedroncelli, File)<\/p>\n