Jayesh Mishra, a California resident, faced unexpected medical bills for his psoriatic arthritis treatment despite relying on a co-pay card, highlighting the complexities of pharmaceutical assistance programs.
In 2025, Jayesh Mishra, a resident of Mission Viejo, California, began experiencing scaly, itchy red patches on his skin. This was soon accompanied by painful swelling in the joints of his hands, making it increasingly difficult for him to perform his job at a bank.
After consulting his primary care physician, Mishra was referred to a rheumatologist, who diagnosed him with psoriatic arthritis. Although there is no cure for the condition, the doctor informed him that several new medications could effectively manage the autoimmune disease. She recommended Otezla, a medication specifically approved for treating psoriatic arthritis.
Initially, Mishra hesitated to start the treatment due to concerns about the high cost of the medication and potential side effects. He thought he could manage his symptoms with over-the-counter drugs. However, by September, the pain had become unbearable, prompting him to accept a starter pack provided by Otezla’s manufacturer, Amgen. The medication proved effective, alleviating both his skin lesions and joint pain, which had been disrupting his sleep.
With the support of his rheumatologist, Mishra obtained approval for Otezla from his insurer, UnitedHealthcare, and enrolled in Amgen’s copayment assistance program. His doctor assured him that the co-pay card, which functions similarly to a credit card, would cover a significant portion of the medication’s high list price—approximately $5,000 for a 30-day supply, as reported by GoodRx.
Mishra was informed that the copay card would cover up to $9,450 annually, leading him to feel relieved. “I was happy when I got the message,” he recalled, noting that his doctor had reassured him, saying, “You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.”
Initially, Mishra paid nothing for his medication. However, that changed when he received his second bill.
For the second month’s supply of Otezla, Mishra was billed $441.02. Faced with the reality of his copay card being depleted, he chose to ration his medication rather than refill his prescription. The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx, revealed that it had not provided a negotiated discount, covering only $308.34 of the total charge of $5,253.85 for a 30-day supply. This left Mishra responsible for the remaining balance.
The situation reflects a broader issue within the healthcare system, where copay assistance programs often create a “tug-of-war” between drug manufacturers and insurers, according to Aaron Kesselheim, a professor of medicine at Harvard Medical School. As insurers increasingly restrict the use of copay cards, their value has become less predictable. Many insurance plans do not count the funds from copay programs toward a patient’s deductible, leaving patients vulnerable to high out-of-pocket costs.
“When you purchased your medication, a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements noted in small print. It further stated that the amount covered by the copay card “was not applied towards your Deductible and Out of Pocket Maximum.”
Caroline Landree, a spokesperson for UnitedHealthcare, clarified that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”
In contrast, Elissa Snook, a spokesperson for Amgen, emphasized that copay assistance programs are intended to help patients initiate and maintain their prescribed therapies. However, she acknowledged that the value of this assistance can diminish quickly when health plans require patients to pay the full list price of a medication.
In the United States, the list prices for brand-name drugs can be prohibitively high, making it difficult for many patients to afford necessary medications. Insurers often negotiate discounts through pharmacy benefit managers, which can lead to significant savings for patients. However, copay assistance programs can complicate this dynamic, as they may encourage patients to opt for more expensive brand-name drugs instead of exploring cheaper alternatives.
Despite the availability of a generic version of Otezla since 2021, Amgen has taken legal action to block U.S. sales of its generic competitors, ensuring the brand-name drug remains protected by patent until 2028. In other countries, including Canada, patients can often purchase Otezla for significantly less, sometimes under $100 a month.
Mishra humorously noted that one of his children suggested he could fund a trip to visit relatives in India simply by purchasing his medication while there.
As the months progressed, Mishra faced mounting challenges with his health plan, which included a $5,000 deductible and a tax-free health savings account (HSA). After using the copay card for his first month’s supply of Otezla, he found that the card was depleted after the second month. He resorted to using his HSA to cover the remaining balance of approximately $400.
Concerned about the costs for subsequent months, Mishra began rationing his medication, skipping doses to extend his supply. Unfortunately, this led to a resurgence of his symptoms. In January, he received another copay card, again valued at $9,450, but it still fell short of covering the full cost of his medication. He again used his HSA to pay the remaining balance, which amounted to $550.
As his symptoms improved, Mishra contacted UnitedHealthcare in late February to inquire about the cost for March’s supply. He was informed that he would need to pay $4,450 to meet his out-of-pocket maximum. Upon further inquiry, he learned that the actual price was $6,995.36.
Mishra’s experience underscores the complexities and challenges associated with copay cards and pharmaceutical assistance programs. While these programs can provide crucial support for patients, they often come with unexpected limitations and costs. As Mishra aptly put it, “Personally, I’m not in financial distress—I can afford it. But it was sticker shock, and it just doesn’t seem right.”
This case highlights the need for patients to thoroughly understand their insurance plans and the implications of using copay cards, as well as the importance of discussing medication options with healthcare providers.
According to KFF Health News, Mishra’s story is part of a larger investigation into medical billing practices and the challenges faced by patients in navigating the healthcare system.