Elisabeth Rosenthal
Over the course of 2025, Jayant Mishra of Mission Viejo, California, progressively developed scaly, itchy crimson patches on his pores and skin. Then got here the ache and swelling within the joints of his arms, making it tough to do his work at a financial institution.
His main care physician referred him to a rheumatologist, who identified psoriatic arthritis. She suggested Mishra that whereas there’s no remedy, there have been many new medicines that might hold the autoimmune illness in test, and he or she really useful one, Otezla.
At first, Mishra balked. He knew the medicines have been costly. He frightened about unwanted side effects. He thought he might handle with over-the-counter medicine.
But by September he was in a lot ache that he agreed to attempt a starter pack offered by Otezla’s producer, Amgen. It labored: The pores and skin lesions disappeared, and the joint ache that saved him up at evening dissipated. He was offered.
His rheumatologist received approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment help program. Having enrolled different sufferers, she advised Mishra the copay card, much like a bank card, ought to final a 12 months, he mentioned, shielding him from the drug’s excessive listing worth: round $5,000 for a 30-day provide, according to GoodRx.
He mentioned the physician defined that, in her sufferers’ expertise, insurers and their pharmacy profit managers negotiated a deeply discounted worth with Amgen — she estimated $1,400 to $2,200 a month. Patients paid a share of that quantity, their “patient responsibility,” utilizing the copay card.
Mishra mentioned he was accepted for a copay card overlaying $9,450 a 12 months. “I was happy when I got the message,” he mentioned.
He added that the physician reassured him about the associated fee. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”
He began the medication and, at first, paid nothing.
Then the invoice got here.
The Medical Service
Otezla, which is available in a capsule, is accepted to deal with some autoimmune problems, together with psoriatic arthritis.
The Bill
$441.02, for the second month’s fill of the drug — earlier than Mishra selected to ration quite than refill his prescription, as a result of his copay card was empty.
The insurance coverage assertion from UnitedHealthcare’s pharmacy profit supervisor, Optum Rx — one other subsidiary of the identical mum or dad firm, UnitedHealth Group — confirmed it didn’t present a negotiated low cost and coated simply $308.34 of the complete $5,253.85 cost for a 30-day provide. The costs for the second month depleted the copay card and left Mishra owing the steadiness.
The Billing Problem: Copay Card ‘Tug-of-War’
Copay help applications are a part of a “tug-of-war between drug manufacturers and insurers,” mentioned Aaron Kesselheim, a professor of medication at Harvard Medical School who research the pharmaceutical trade.
The worth of drugmakers’ copay playing cards has turn out to be extra unpredictable as insurers attempt to prohibit their use. Many insurance coverage, for example, don’t rely the cash from a copay program toward a patient’s deductible.
And sufferers who use a copay card can wind up paying full or practically full worth quite than the discounted fee negotiated by their insurer’s pharmacy profit supervisor.
“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s rationalization of advantages statements learn, in tiny letters. The quantity the copay card coated “was not applied towards your Deductible and Out of Pocket Maximum.”
Caroline Landree, a spokesperson for UnitedHealthcare, mentioned that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”
In an emailed assertion, Elissa Snook, a spokesperson for Amgen, expressed a special view of who was answerable for Mishra’s dilemma: “Copay 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.”
Few sufferers can afford the listing costs that pharmaceutical producers cost within the United States for brand-name medicine.
Insurers insulate themselves and their prospects from these larger costs by means of pharmacy profit managers’ negotiated reductions. They may, for instance, designate sure medicine as most popular medicines for plan members in change for the producer agreeing to a big worth discount.
Manufacturers’ copay help applications provide one other method for sufferers to keep away from paying full worth. The help is meant to encourage sufferers to decide on an costly, brand-name drug — not one which “treats the same condition that the insurer has gotten for a cheaper price,” mentioned Fiona Scott Morton, an economist on the Yale School of Management who research drug pricing.
The help additionally discourages sufferers from discussing with their physician whether or not a less expensive, generic drug would do, drug trade researchers mentioned.
While the Food and Drug Administration first accepted a generic model of Otezla in 2021, Amgen has sued to block U.S. sales of its generic rivals, guaranteeing the brand-name drug has patent safety till 2028. Generic variations can be found abroad and in Canada, the place sufferers should purchase it in some circumstances for less than $100 a month.
Mishra mentioned certainly one of his youngsters joked he might cowl a visit to go to kinfolk in India just by buying his drugs whereas he was there.
The Resolution
Mishra has a well being plan with a $5,000 deductible and contributes to a tax-free well being financial savings account.
In September, he paid for the primary month’s provide of Otezla with the copay card. But paying for October’s provide emptied the cardboard — which he initially anticipated to final a 12 months — and he mentioned he used his HSA to pay for the roughly $400 that remained.
But cautious of what the drug would value in November and December, Mishra mentioned, he tried to unfold out the tablets he had left from the starter pack and the primary two months’ provide. He skipped some days and took solely half of the prescribed dose to stretch the provision for 2 extra months, figuring out he would get a brand new copay card with the brand new 12 months. Many of his signs returned, he mentioned.
In January, he received one other copay card, good for $9,450, which once more wasn’t ample to pay for 2 months’ provide. He once more paid the remaining steadiness in February from his HSA to rely towards his $5,000 annual deductible. This time he owed $550, he mentioned.
Mishra mentioned his signs have resolved. With no clue what he’d be charged for March’s provide, he known as UnitedHealthcare in late February and was advised he would wish to pay $4,450 for the month to fulfill his out-of-pocket most, he mentioned.
But he mentioned he pressed the consultant additional, asking why UnitedHealthcare doesn’t have a negotiated worth. It does, they advised him. “Actual price is $6,995.36.”
The Takeaway
Copay playing cards and drugmaker applications that promise sufferers “you could pay $0” work in mysterious methods.
On the one hand, they encourage sufferers to make use of brand-name or costly medicine which might be off insurers’ formularies, or lists of most popular, coated medicine. On the opposite, many sufferers couldn’t afford prescribed medicines with out them.
Patients with public insurance coverage, comparable to Medicare and Medicaid, are usually not permitted to make use of the playing cards, as a result of the federal government considers them an end run around its attempts to bring down drug spending.
Using a copay card has gotten trickier as insurers push back. First, patients need to understand whether there is an annual dollar or time limit on the card and how it works with their insurance. Otherwise, they risk ending up reliant on a drug they can’t afford.
Less expensive drugs often can suffice. For example, there are a number of medicines to treat psoriatic arthritis, some of which may be cheaper or have better coverage from a particular insurer. Patients should ask their doctors whether cheaper medicines will work.
It also can help patients to consider their prescriptions when they select a health plan. Landree, of UnitedHealthcare, said Mishra could have selected a plan for 2026 that would have covered Otezla for a $100 copay each month, though that would have meant a higher premium.
“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.”
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical payments. Since 2018, this collection has helped many sufferers and readers get their medical payments diminished, and it has been cited in statehouses, on the U.S. Capitol, and on the White House. Do you may have a complicated or outrageous medical invoice you need to share? Tell us about it!
