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

During the year 2025, Jayant Mishra of Mission Viejo, California, gradually developed scaly, itchy red patches on his skin. Then came pain and swelling in the joints of his hands, making it difficult to work in a bank.

His GP referred him to a rheumatologist, who diagnosed psoriatic arthritis. She informed Mishra that while there is no cure, there are many new medications that could control the autoimmune disease, and she recommended one, Otezla.

At first, Mishra hesitated. He knew the drugs were expensive. He was worried about the side effects. He thought he could get by on over-the-counter medications.

But by September, he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: the skin lesions disappeared and the joint pain that kept him up at night dissipated. It was sold.

His rheumatologist got the drug approved by his insurer, UnitedHealthcare, and enrolled him in Amgen’s copayment assistance program. After signing up other patients, she told Mishra that the copay card, similar to a credit card, should last a year, he said, protecting him from the drug’s high list price: about $5,000 for a 30-day supply, according to GoodRx.

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen — she estimated between $1,400 and $2,200 per month. Patients paid a percentage of this amount, their “patient responsibility,” using the copay card.

Mishra said he got a co-pay card covering $9,450 a year. “I was happy when I received the message,” he said.

He added that the doctor reassured him about the cost. “She said, ‘You shouldn’t have to pay anything out of pocket. Your co-pay card will cover that.'”

He started taking the medication and at first he didn’t pay anything.

Then the bill arrived.

The medical service

Otezla, which comes in pill form, is approved to treat certain autoimmune diseases, including psoriatic arthritis.

The bill

$441.02, for the second month’s treatment – ​​before Mishra chose to ration rather than refill his prescription, because his co-pay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx — another subsidiary of the same parent company, UnitedHealth Group — showed that it did not offer a negotiated discount and only covered $308.34 of the full $5,253.85 charge for a 30-day supply. The second month’s charges depleted the copay card and left Mishra owing the balance.

The billing problem: the “tug of war” of the Copay card

Copay assistance programs are part of a “tug of war between drugmakers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for example, don’t count money from a co-pay program toward a patient’s deductible.

And patients who use a copay card may end up paying full or near full price instead of the discounted rate negotiated by their insurer’s pharmacy benefits manager.

“When you purchased your medicine, a manufacturer’s coupon was used,” Mishra’s explanation of the benefit claims reads in tiny letters. The amount covered by the copay card “has not been applied to your deductible and out-of-pocket maximum.”

Caroline Landree, a spokeswoman for UnitedHealthcare, said “the copay card is an agreement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, an Amgen spokeswoman, expressed a different view on who is responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients begin and continue a prescribed treatment, but the value of that assistance may run out more quickly when a health plan requires patients to pay the full list price of a drug.” »

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers protect themselves and their customers from these higher prices through discounts negotiated by pharmacy benefit managers. They could, for example, designate certain drugs as preferred drugs by plan participants in exchange for the manufacturer accepting a significant price reduction.

Manufacturer assistance programs offer patients another way to avoid paying full price. The aid is intended to encourage patients to choose an expensive brand-name drug — not one that “treats the same disease that the insurer got at a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug prices.

The help also discourages patients from arguing with their doctors about whether a cheaper generic drug would do the job, pharmaceutical industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen sued to block U.S. sales of its generic competitors, ensuring that the brand-name drug has patent protection until 2028. Generic versions are available abroad and in Canada, where patients can buy them in some cases for less than $100 a month.

Mishra said one of his children joked that he could cover a trip to visit relatives in India simply by buying his medicine while he was there.

The resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply drained the card — which he initially expected to last a year — and he said he used his HSA to pay off the roughly $400 that remained.

But wary of the drug’s price in November and December, Mishra said he tried to stretch out the pills he had left from the starter box and the first two months’ supply. He skipped a few days and took only half the prescribed dose to extend the supply for two more months, knowing he would get a new co-pay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, worth $9,450, which again wasn’t enough to pay for two months’ supply. He paid the remaining February balance on his HSA again to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms had disappeared. Having no idea what he would be charged for the March supply, he called UnitedHealthcare in late February and was told he would have to pay $4,450 for the month to reach his maximum amount, he said.

But he said he pressed the representative further, asking why UnitedHealthcare didn’t have a negotiated price. It’s true, they told him. “Actual price is $6,995.36.”

Takeaways

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive medications that are not listed on insurers’ formularies, or on lists of preferred and covered medications. On the other hand, many patients would not be able to obtain prescribed medications without them.

Patients with public insurance, such as Medicare and Medicaid, are not allowed to use these cards because the government views them as a means to circumvent its attempts to reduce drug spending.

Using a co-pay card has become trickier as insurers respond. First, patients should understand if there is an annual limit or term limit on the card and how that works with their insurance. Otherwise, they risk finding themselves dependent on a medication they cannot afford.

Cheaper medications can often be enough. For example, there are a number of medications to treat psoriatic arthritis, some of which may be less expensive or have better coverage with a particular insurer. Patients should ask their doctor if cheaper medications will work.

It can also help patients consider their prescriptions when selecting a health plan. Landree, of UnitedHealthcare, said Mishra could have selected a plan for 2026 that would have covered Otezla for a copay of $100 per month, even though that would have meant a higher premium.

“Personally, I am not in financial difficulty, I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”

Bill of the Month is a participatory survey carried out by KFF Health News And The Well-Being of the Washington Post which dissects and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills, and it has been cited in states, at the U.S. Capitol, and at the White House. Do you have a confusing or scandalous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF’s primary operating programs, an independent source of health policy research, polling and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).