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

His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

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. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

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 $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got 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 copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

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

The Billing Problem: Copay Card ‘Tug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers 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 instance, do not count the money from a copay program .

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

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

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

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

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug — not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing 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 emptied the card — which he originally expected to last a year — and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

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

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

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

The Takeaway

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 drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them an end run around its attempts to bring down drug spending.

Using a copay card has gotten trickier as insurers push back. First, patients need to understand whether there is an annual dollar or time limit on the card and how it works with their insurance. Otherwise, they risk ending up reliant on a drug they can’t afford.

Less expensive drugs often can suffice. For example, there are a number of medicines to treat psoriatic arthritis, some of which may be cheaper or have better coverage from a particular insurer. Patients should ask their doctors whether cheaper medicines will work.

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

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

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