He Needs an Expensive Drug. A Copay Card Helped — Until It Didn’t.

Over the course of 2025, Jayant Mishra of Mission Viejo, California, progressively developed scaly, itchy pink patches on his pores and skin. Then got here the ache and swelling within the joints of his fingers, making it tough to do his work at a financial institution.

His main care physician referred him to a rheumatologist, who recognized psoriatic arthritis. She suggested Mishra that whereas there’s no remedy, there have been many new medicines that would maintain the autoimmune illness in verify, and he or she really helpful one, Otezla.

At first, Mishra balked. He knew the medicines have been costly. He nervous about uncomfortable side effects. He thought he may handle with over-the-counter medication.

However by September he was in a lot ache that he agreed to attempt a starter pack supplied by Otezla’s producer, Amgen. It labored: The pores and skin lesions disappeared, and the joint ache that stored him up at evening dissipated. He was bought.

His rheumatologist acquired approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment help program. Having enrolled different sufferers, she informed Mishra the copay card, just like a bank card, ought to final a yr, he stated, shielding him from the drug’s excessive checklist worth: round $5,000 for a 30-day provide, based on GoodRx.

He stated 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. Sufferers paid a proportion of that quantity, their “affected person accountability,” utilizing the copay card.

Mishra stated he was accredited for a copay card overlaying $9,450 a yr. “I used to be completely happy once I acquired the message,” he stated.

He added that the physician reassured him about the fee. “She stated: ‘You shouldn’t must pay something out-of-pocket. Your copay card will cowl this.’”

He began the drugs and, at first, paid nothing.

Then the invoice got here.

The Medical Service

Otezla, which is available in a capsule, is accredited to deal with some autoimmune problems, together with psoriatic arthritis.

The Invoice

$441.02, for the second month’s fill of the drug — earlier than Mishra selected to ration somewhat 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 father or mother firm, UnitedHealth Group — confirmed it didn’t present a negotiated low cost and lined simply $308.34 of the total $5,253.85 cost for a 30-day provide. The costs for the second month depleted the copay card and left Mishra owing the stability.

The Billing Drawback: Copay Card ‘Tug-of-Battle’

Copay help packages are a part of a “tug-of-war between drug producers and insurers,” stated Aaron Kesselheim, a professor of medication at Harvard Medical College who research the pharmaceutical trade.

The worth of drugmakers’ copay playing cards has change into extra unpredictable as insurers attempt to prohibit their use. Many insurance policy, as an example, don’t depend the cash from a copay program towards a affected person’s deductible.

And sufferers who use a copay card can wind up paying full or practically full worth somewhat than the discounted charge negotiated by their insurer’s pharmacy profit supervisor.

“Whenever you bought your remedy a Producer Coupon was used,” Mishra’s clarification of advantages statements learn, in tiny letters. The quantity the copay card lined “was not utilized in the direction of your Deductible and Out of Pocket Most.”

Caroline Landree, a spokesperson for UnitedHealthcare, stated that “the copay card is an association between the affected person and the pharmacy. It’s used exterior of insurance coverage.”

In an emailed assertion, Elissa Snook, a spokesperson for Amgen, expressed a unique view of who was answerable for Mishra’s dilemma: “Copay help packages are designed to assist sufferers begin and keep on prescribed remedy, however the worth of that help might be exhausted extra rapidly when a well being plan requires sufferers to pay the total checklist worth of a medication.”

Few sufferers can afford the checklist costs that pharmaceutical producers cost in the USA for brand-name medication.

Insurers insulate themselves and their clients from these larger costs by means of pharmacy profit managers’ negotiated reductions. They could, for instance, designate sure medication as most popular drugs for plan members in change for the producer agreeing to a major worth discount.

Producers’ copay help packages supply one other means 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 identical situation that the insurer has gotten for a less expensive worth,” stated Fiona Scott Morton, an economist on the Yale College of Administration 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 stated.

Whereas the Meals and Drug Administration first accredited a generic model of Otezla in 2021, Amgen has sued to dam U.S. gross sales of its generic opponents, 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 lower than $100 a month.

Mishra stated certainly one of his kids joked he may cowl a visit to go to family members in India just by buying his drugs whereas he was there.

The Decision

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. However paying for October’s provide emptied the cardboard — which he initially anticipated to final a yr — and he stated he used his HSA to pay for the roughly $400 that remained.

However cautious of what the drug would price in November and December, Mishra stated, 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 availability for 2 extra months, realizing he would get a brand new copay card with the brand new yr. Lots of his signs returned, he stated.

In January, he acquired one other copay card, good for $9,450, which once more wasn’t adequate to pay for 2 months’ provide. He once more paid the remaining stability in February from his HSA to depend towards his $5,000 annual deductible. This time he owed $550, he stated.

Mishra stated his signs have resolved. With no clue what he’d be charged for March’s provide, he referred to as UnitedHealthcare in late February and was informed he would want to pay $4,450 for the month to satisfy his out-of-pocket most, he stated.

However he stated he pressed the consultant additional, asking why UnitedHealthcare doesn’t have a negotiated worth. It does, they informed him. “Precise worth is $6,995.36.”

The Takeaway

Copay playing cards and drugmaker packages that promise sufferers “you can pay $0” work in mysterious methods.

On the one hand, they encourage sufferers to make use of brand-name or costly medication which can be off insurers’ formularies, or lists of most popular, lined medication. On the opposite, many sufferers couldn’t afford prescribed medicines with out them.

Sufferers with public insurance coverage, akin 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 finish run round its makes an attempt to convey down drug spending.

Utilizing a copay card has gotten trickier as insurers push again. First, sufferers want to know whether or not there may be an annual greenback or time restrict on the cardboard and the way it works with their insurance coverage. In any other case, they danger ending up reliant on a drug they’ll’t afford.

Cheaper medication typically can suffice. For instance, there are a selection of medicines to deal with psoriatic arthritis, a few of which can be cheaper or have higher protection from a selected insurer. Sufferers ought to ask their docs whether or not cheaper medicines will work.

It additionally may also help sufferers to contemplate their prescriptions after they choose a well being plan. Landree, of UnitedHealthcare, stated Mishra may have chosen a plan for 2026 that might have lined Otezla for a $100 copay every month, although that might have meant a better premium.

“Personally I’m not in monetary misery — I can afford it,” Mishra stated. “However it was sticker shock, and it simply doesn’t appear proper.”

Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Publish’s Nicely+Being that dissects and explains medical payments. Since 2018, this sequence 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 Home. Do you’ve got a complicated or outrageous medical invoice you need to share? Inform us about it!