ADVI Instant: Colorado PDAB Votes to Establish an Upper Payment Limit for Enbrel

On February 23, 2024, the Colorado Prescription Drug Affordability Board (PDAB) voted unanimously to move forward with establishing an upper payment limit (UPL) for Enbrel. This is the first time a PDAB has voted to set a UPL for a selected product.

If implemented, the UPL will govern what purchasers can pay and state-regulated payers can reimburse for prescriptions dispensed or administered to individuals in the state. The UPL would be optional for self-insured health plans regulated under the Employee Retirement Income Security Act of 1974 (ERISA).

The Board also discussed the proposed timeline for establishing a UPL for Enbrel.

• While the timeline is flexible, PDAB staff stated that the entire UPL setting process is expected to take around 6 months.
  • The Board will review the PDAB’s rules and policies for establishing a UPL at the March 15 and April 26 meetings.
  • Two Enbrel UPL Rulemaking hearings are scheduled for June 7 and July 19 (subject to change).
• PDAB staff also noted that the process can be stopped at any time, stating that the Board’s vote to initiate “does not mean that [the board] is bound to complete the UPL process.”

The Colorado PDAB has now completed affordability reviews for three of the five products it selected. At previous meetings, the Board voted that Trikafta and Genvoya are “not unaffordable”, meaning that the PDAB cannot move forward with setting UPLs. The Board will complete affordability reviews for the remaining products, Cosentyx and Stelara, over the next several months.

ADVI will continue monitoring developments and the next steps. This is a delayed release. ADVI Instant content is distributed in real-time for retainer clients. Get in touch to learn more about how we can support your commercialization, market access, and policy needs.

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