Colorado Board Aims to Curb Prescription Drug Costs

Without the anti-inflammatory medication for his rheumatoid arthritis, John Crider, a 67-year-old retiree who lives north of Denver, suffers from intense pain that can hinder his ability to walk or do other daily activities.

When he was still covered by private insurance through his employer, he could afford the $10-a-month cost for his prescription. But when he retired and switched to Medicare, he learned his out-of-pocket cost would be $585 per month.

It was “a rude awakening,” says Crider, who worked in the health care field.

The drug Crider needs is called Enbrel, and it’s the first medication that Colorado’s Prescription Drug Affordability Board has deemed “unaffordable” for consumers. The board—created by the General Assembly in 2021—has the power to set upper payment limits for certain pricey drugs.

Other states have set up similar boards, but Colorado’s is the first in the country to label a drug unaffordable. The board found that 3,406 Coloradans used the drug in 2022, at an average annual out-of-pocket cost of $2,295, according to its report.

The board’s staff is now in the midst of a lengthy process to calculate a maximum price that may be paid or billed for Enbrel, also known as etanercept. It is used to treat rheumatoid arthritis and several other conditions.

Meanwhile, the drug’s maker, Amgen Inc., has sued to stop the board’s actions. The case is now pending in a Denver federal court.

The board’s actions—and the drugmaker’s lawsuit—put Colorado at the “forefront” in the battle to address high drug costs, says Jon Bartholomew, a government affairs director in AARP’s national office. The outcome will help inform how other state policymakers address high drug costs, he adds.

High costs, tough choices

More than 540,000 Coloradans—nearly 10 percent—reported not filling a prescription because of costs in 2021, according to a survey by the Colorado Health Institute, a nonprofit research and consulting group. Of those, 40 percent said their condition worsened.

Across the country, policymakers are considering a range of strategies to keep their constituents from having to choose between paying for their medications or food, gas and housing. Drug affordability review boards have been deployed as a tool in several states.

In addition to Colorado, legislators in Maryland, Minnesota and Washington have created boards with the authority to determine upper payment limits for expensive medications. Nine other states have boards that cannot set payment limits but can make recommendations on policies to lower costs, AARP research shows.

In October, Maryland’s board received approval to conduct cost reviews of six drugs.

“These states are ... putting in a lot of effort to really do a lot of due diligence and understand the market and take these steps, but it’s still early days in terms of actual implementation,” says Hemi Tewarson, executive director of the National Academy for State Health Policy, a nonpartisan organization working with states to develop innovative health policies.

Colorado’s drug board determined in February of 2024 that Enbrel was unaffordable after reviewing everything from the drug’s effectiveness to the out-of-pocket costs for Coloradans. Last summer, the board ruled that Johnson & Johnson’s Stelara and Novartis AG’s Cosentyx—also anti-inflammatory drugs—were unaffordable as well.

Amgen’s suit over Enbrel, filed in March of 2024, argues the board's regulatory powers conflict with federal patent laws and violate several clauses of the U.S. Constitution. The Colorado attorney general’s office is seeking to dismiss the suit.

Amgen did not respond to the Bulletin’s request for comment. But in a legal brief, the company said the board's “decision-making is effectively a black box” and the criteria it uses to label a drug unaffordable are “extraordinarily broad and vague.”

Karen Moldovan, AARP Colorado’s advocacy director, says the board has “an incredibly rigorous process” in which they look at every facet of the medication, from supply chain to manufacturing issues to the consumer perspective.

Crider, the Denver-area retiree, is among those who have had to ration medication. Instead of taking Enbrel once a week—as prescribed—he stretched out the dosing, first to two weeks, then three, then six. The price for that strategy? Two episodes of severe discomfort.

Starting in 2025, he and other Medicare beneficiaries will get some relief in the form of Medicare’s new out-of-pocket maximum of $2,000 a year for prescription drugs. That’s still “not cheap,” he says, “but it’s something I can afford.” ■

Cynthia Pasquale is a freelance writer and former editor at The Denver Post. She has written for the Bulletin since 2011.

 Also of interest:

• 3 Big Medicare Prescription Drug Changes Coming in 2025
• 5 Actions to Take for 2025 During Medicare Open Enrollment
• 12 Things That Are Free Under Medicare
  
  How to Cut Costs on Rx Drugs