Prescription Drug Affordability Board Activity, October 2025

Sophie Thomas updated the board and the public that the stakeholder workgroup would have its first meeting on October 14th. The workgroup will identify opportunities to improve practices for collecting patient information during affordability review processes. 

Staff give a presentation about the high-level effects of setting an upper payment limit UPL. The statute says that the board will be able to monitor implementation by reviewing carrier data, by requesting information for annual general assembly reports, and by accepting public comment after a UPL is set. The division of insurance, on the other hand, can monitor implementation by accepting information from providers, pharmacies, and patients; by conducting market analysis of carrier and PBM behaviors; and by examining data from APCD, carrier-submitted data about formularies and prior authorization, and rebates and drug-specific impacts on premiums. 

Staff also reviewed UPL benchmarks, May-to-October data about public testimony, and data from 2025 rulemaking hearings. The board also examined data that staff put together about Enbrel, including the maximum fair price and the average plan paid amount, that led it to deem Enbrel unaffordable. 

Next, they turned to proposed changes to the rule, including a minor change in the UPL dollar amount and setting a defined unit and an effective date. Staff recommended changing the dollar amount to $584 per unit to ensure alignment with the maximum fair price (MFP) per unit, and suggested setting the UPL unit at 1 milliliter, and mentioned that it would provide clarity for pediatric patients who would be taking half a unit. Staff also proposed a January 1, 2027 effective date instead of the current language, “at least six months after the adoption date.” 

The board spoke at length about the unit given in the rule and how it would work with the different dosings and forms (syringes and vials) of Enbrel. The board entered an executive session to receive legal advice about the dollar amount in relation to the MFP and the usage of the unit in the rule. They changed the rule to say “50mg” in addition to the 1 milliliter  that staff recommended and added a sentence: “The price per unit will apply to all commercially available formulations, including the unreconstituted powder vial.” They also changed the dollar amount to $600, for fear of being too close to the MFP, which is not legal. 

The board agreed on January 1, 2027 as the best effective date, given the requirement to give at least 6 months and carrier concerns that contracts are usually reworked at the beginning of each year. 

8 people spoke at the meeting. Additional written testimony is here: 1 | 2 

Tiffany Westrich-Robertson, speaking on behalf of the EACH/PIC coalition and as a person with a disease treated by Enbrel, shared concerns that the history of cost shifting, utilization management, and non-medical switching will be repeated. She said that she appreciated board discussion about how to avoid these problems, but felt that these concerns, which have been raised by many patient advocacy organizations, have been minimized. The board chair replied that non-UPL solutions to affordability challenges are not part of the statute, so they are not able to address them.

Sophia Hennessy, from the Colorado Consumer Health Initiative, expressed support for setting the UPL for Enbrel at the MFP. She believes that that federally negotiated data is the best data available for Enbrel, and supports the annual adjustment order that is in the rule.

Derek Flowers, from the Value of Care Coalition, talked about the board ignoring other factors that are driving drug costs, like benefit design or co-pays. He also spoke about failures that are playing out federally, with early results showing that out-of-pocket costs for MFP medicines have risen by an average of 32% and that some independent pharmacies are not stocking them.

Katelin Lucariello, on behalf of PhRMA, expressed continued concern about the lack of methodology for the UPL-setting process. She would prefer a statutorily required approach that would be consistent among all drugs that are considered for a UPL to relying on a federal benchmark. She also mentioned a lack of clarity about how the UPL will be reviewed. The board asked about her thoughts on the January 2027 timing in the draft rule. She said that she appreciated the board listening to the supply chain stakeholders’ comments on the timing, but could not speak about specific members’ opinions. Multiple board members pushed back on the notion that they are relying only on the MFP, and that the same process will work for every drug.

Amy Goodman, with the Colorado BioScience Association, said that UPLs are an ineffective and counterproductive tool to accomplish the PDAB’s goal. She had concerns about the lack of clear standards and processes for UPL-setting, especially given the reliance on MFPs and the small number of drugs that have an established MFP. She pointed out that the PDAB statute requires the board to determine by rule the methodology for establishing a UPL and said that the board had not done so in a way that could be repeated for other drugs. She was concerned that the board had not considered setting a dosage for the UPL before the meeting.

Rae Wall, a Denver resident and patient who advocates for the lowering of the cost of prescription medication, testified about the struggle to afford life-saving drugs. She expressed her support for setting a UPL and working towards lowering the cost of medication.

Dr. Madelaine Feldman, on behalf of the Coalition of State Rheumatology Organizations, suggested that setting a UPL on Enbrel could lead to it being excluded from formularies or placed on higher tiers. She said that PBMs choose medications for their formularies based on manufacturer kick-backs, which leads manufacturers to raise prices in the hopes of outbidding other manufacturers to end up on PBM formularies. She pointed out that there's nothing in the PDAB law that requires PBMs to place UPL drugs on the formulary, which could leave UPL drugs out of reach of consumers.

Dr. Ingrid Pan, a pediatric rheumatology pharmacist, testified about the dosing of Enbrel for pediatric patients and talked about billing and prescribing Enbrel in the pediatric population, and how weight-based dosing complicates it. She did not have an issue with the verbiage of the draft rule.

The board revisited the draft rule. They decided to delete “including but not limited to commercially available formulations, such as the unconstituted powder vial,” following public comment. The board adopted the rule to set a UPL limit for Enbrel, effective January 1, 2027. 

Staff presented a presentation about UPL implementation, which they are in the process of creating guides for. They mentioned developing a communication plan to ensure that carriers, providers, and consumers know about the price cap and the effective date. They also spoke about the manufacturer inquiry process, which is required through the statute, and requires reaching out to the manufacturers to identify whether or not they will continue to provide and give access to the UPL drug in Colorado. Staff are creating guides for the partnership with carriers with two requirements: a carrier appeal process for UPLs and the carrier's use of the savings report. Lastly, they are creating a UPL monitoring and board communication roadmap, identifying what data they have access to and what data they need to ensure access to Enbrel is not disrupted. 

Staff then presented a timeline beginning with the manufacturer inquiry, which they have 30 days to respond to. Based on that response, they will issue a notice to consumers and pharmacies about next steps, including requesting implementation information from the carriers. 

One board member asked about how, in this process, the board will ensure that Enbrel is not dropped from formularies. Staff suggested that they would address this as a part of the carrier implementation data. 

Emily Zadvorny, CEO of the Colorado Pharmacist Society, asked the board if they had any authority over setting a reasonable dispensing fee. She wanted to address the pharmacies’ concerns about having no margin now that a UPL has been implemented. The board clarified that they don’t have any authority to set a reasonable dispensing fee. They talked about the possibility of the board communicating with the legislature before the General Assembly Report is due in July. 

Primo Castro, from the Biotechnology Innovation Organization, spoke about the lack of negotiation in the MFP price-setting process and potential access issues that the MFP may create for rare disease patients. He also spoke about lack of innovation in countries with nationalized healthcare systems. 

Carl Eklund, a caregiver for his mother, spoke about PBMs being the real driver for high medication costs and asked the board to ensure that access to medicine was not restricted now that a UPL had been set. He also asked whether all the members of the board are from Colorado. The board chair replied that that was correct.