Colorado’s EpiPen Cost Cap Proves Tricky to Implement

Colorado’s EpiPen cost cap has proven trickier to implement than the state’s limits on insulin expenses, with some families struggling to find a pharmacy that will sell them the medical devices for the required $60. One of the law’s main sponsors and some pharmacies point the finger at manufacturers, who they allege are refusing to follow the law as insulin makers did. House Bill 1002, which took effect in January, limits the out-of-pocket cost of epinephrine auto-injectors to $60 for a pack of two for most people, through a co-pay cap and a separate affordability program.

Epinephrine, also known as adrenaline, stops a person’s blood pressure from plummeting to unsafe levels and their airway from swelling shut during an allergic reaction. People who have severe allergies to certain foods or to bee stings have to carry epinephrine in case of accidental exposure.

Colorado’s co-pay cap only applies to health insurance plans regulated by the state, and, so far, that part appears to be running relatively smoothly. Since the cap took effect in January, the state Division of Insurance has received only four complaints, and in three of those cases, the complainant had insurance that the state doesn’t regulate, spokesman Vince Plymell said. The division is still investigating the fourth case. The rollout of the affordability program, which covers people with no insurance or plans regulated outside Colorado, has been bumpier, even though it closely resembles the program Colorado instituted in 2022 to limit the out-of-pocket cost of insulin to $50 per month. Theoretically, epinephrine users who can prove they are Colorado residents only have to fill out an application, pay $60 at any pharmacy that stocks EpiPens and go on their way with their medication. Epinephrine manufacturers are required to reimburse pharmacies for the full cost of the auto-injectors, or send them replacement stock.

But some families described considerable difficulty using the program.  Rosie Haggard, of Arvada, said she ended up paying $110 out-of-pocket to buy auto-injectors for each of her two children. Her insurance isn’t state-regulated, so the cap doesn’t apply. She said she tried to use the affordability program at multiple chain pharmacies before giving up. “CVS said they don’t have a plan in place, Walgreens said they didn’t have to comply… and King Soopers said they have no clue about the law,” she said.  Representatives of Walgreens, CVS and King Soopers all directed questions to the Colorado Retail Council. President Chris Howes said the group is willing to work with lawmakers on a bill to fix the rollout. “There has been a lack of appropriate guidance, education and notification from state agencies and, frankly, weak regulatory oversight of manufacturer program compliance to ensure that pharmacies are being reimbursed by EpiPen manufacturers,” he said.

Ryan Laird, of Denver, also gave up after weeks of trying to use the program to buy auto-injectors for his wife’s allergies. Their insurance had Walgreens as its in-network pharmacy, but they looked into transferring her prescription to CVS after hitting a wall there. It didn’t go well with CVS, which quoted a price of more than $300, he said. “I’ve contacted four or five different Walgreens, and they all come back with the same, that corporate has not given them any guidance, that they don’t have a (billing) code for it,” he said. Going without epinephrine wasn’t an option, so ultimately they decided to make other budget cuts so they could buy the auto-injectors and try to get reimbursed later, Laird said. But he’s still frustrated with the process. “The whole point of the law is that families don’t have to do this,” he said.

As the situation stands now, pharmacies have no financially viable way to comply, said Tom Gierwatoski, board president of RxPlus Pharmacies, a cooperative that allows independent pharmacies to benefit from lower prices through group purchasing. Manufacturers aren’t reimbursing the cost of auto-injectors they dispense, meaning the pharmacy gets only the $60 the patient pays, he said. “How can we dispense drugs hundreds of dollars below their cost?” he said.

Viatris, which manufactures EpiPens, didn’t directly answer The Denver Post’s questions about reimbursement, but issued a statement saying it is in compliance and provided all necessary information to the Colorado State Board of Pharmacy. The company offers a discount program for up to $300 off co-pays for EpiPens, but it’s only available to people with commercial insurance. A separate program offers $25 off co-pays for the generic version for the same group of people.

Companies have a financial incentive to make sure insured patients don’t stop filling their prescriptions because of out-of-pocket costs: if they do, reimbursement from their insurance also dries up. (Depending on the patient’s deductible and other medical expenses, insurance may cover the majority of the cost of their medication over the course of a year.) If a patient is uninsured, companies don’t gain anything by alleviating their pain at the pharmacy counter, because no one else is picking up the rest of the bill.

Colorado’s epinephrine affordability law allows a fine of up to $10,000 for each month that manufacturers don’t reimburse pharmacies for epinephrine. It also labels noncompliance as a deceptive trade practice, which would allow the Colorado Attorney General’s Office to get involved. The legislature may need to increase penalties, said Sen. Dylan Roberts, a Frisco Democrat who was one of the lead sponsors of the EpiPen affordability bill. In some cases, it may be that pharmacies just aren’t aware the law changed, but if they truly can’t get reimbursed, that would require another bill to bring drugmakers in line, he said.

Independent pharmacies didn’t have the same problem with the insulin affordability program, though that may have been because manufacturers dropped their prices not long after the state implemented it, Gierwatoski said. He supports the intent of the epinephrine law, but said he doubts individual states have the resources to make drug manufacturers comply. “It needs to be enforced at the federal level, not the state level,” he said.

Artice by The Denver Post

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