Insight
The reality facing biopharma brands today is stark: 1 in 4 patients leave the pharmacy without their medication due to cost,[0]CoverMyMeds Patient Survey 2023 nearly 50% of patients abandon therapy when out-of-pocket costs exceed $125[0]IQVIA Medicine Spending & Affordability in the U.S., 2020 and 94% of providers report that prior authorization delays delivery of care.[0]American Medical Association. Health Insurance Denials, Delayed Care & Medication Access: How Prior Authorization Hurts Patients. American Medical Association, 15 July 2024 These aren't isolated problems—they're interconnected challenges that emerge at specific decision points in the patient journey, and they can make the difference between therapy success and abandonment.
Whether or not patients start therapy often comes down to what happens at three decisive moments: when a claim is approved but cost remains a barrier, when coverage is rejected but achievable, and when rejection suggests coverage is unlikely. Many access strategies treat each of these as separate challenges.
But at CoverMyMeds, we've designed configurable solutions that work together across these make-or-break moments, embedded directly into the workflows where providers and pharmacies already operate. Here's how this integrated approach transforms access and affordability at these critical junctures.
The patient's experience: The claim processes successfully, but at pickup, the out-of-pocket cost is too much to swallow. The patient might hesitate, ask to think about it, then leave without the medication.
The challenge for brands: Even after securing formulary access and the prescribing decision, cost at the point of dispense derails therapy starts. This creates a gap between claims approved and prescriptions actually filled.
The solution: Automatic affordability support that applies in real time. Through our network of 50,000+ pharmacies, eligible patients receive automated savings—requiring zero action from the pharmacist or patient—at the moment the claim is processed. For brands seeking broader reach, this can be paired with traditional copay card programs that layer additional savings.
Together, they extend affordability to more patients while built-in safeguards — including OIG-compliant government plan exclusions and maximizer and accumulator mitigation — keep copay investments focused where they’re needed. The result: more than 69 million copay claims processed annually through our pharmacy network and proprietary adjudication platform,[0]CoverMyMeds claims data on file. Date range: January – December 2024 helping prevent abandonment for 12.5 million prescriptions[0]Calendar Year 2024; CoverMyMeds data on file and delivering $10.9 billion in patient savings.[0]Calendar Year 2024; CoverMyMeds data on file
While these results demonstrate scale, what gives individual brands strategic control is configurability. Programs can be tailored to target patient populations that need them. Additionally, real-time claim visibility allows for continuous optimization based on actual claim data and abandonment patterns.
CoverMyMeds embeds configurable solutions working together in provider and pharmacy workflows to transform access and affordability at critical moments that determine therapy success.
The patient's experience: The pharmacy processes the claim, which is immediately rejected. The pharmacist explains that prior authorization is needed. Days or weeks pass. The prescription sits in limbo while the provider's office juggles burdensome paperwork, and the patient, with no way to track progress, waits and worries.
The challenge for brands: When prior authorization processes lack embedded support, they create workflow friction for providers, delay therapy starts and introduce abandonment risk. Without that support, requests stall, denials go uncontested, and patients often give up.
The solution: Brand-specific prior authorization support integrated directly into existing provider and pharmacy workflows. Here’s what that looks like: When a rejection occurs within our connected pharmacy network, a prior authorization is automatically initiated and sent to the provider — without displaying alternative therapies. This keeps your brand front and center while removing initiation friction.
But automation is just the beginning. We embed further support into prior auth workflows that provide supplemental information, intelligent reminders, intervention on stalled requests, and appeal assistance for denied cases. For brands seeking deeper provider engagement, our proprietary data equips your field teams to proactively educate offices with provider-level insights, or you can deploy CoverMyMeds' Field Reimbursement Services staff who bring patient-level data visibility to overcome reimbursement challenges.
The impact is measurable: We've seen a 14-percentage-point improvement in claim approval rates with this prior authorization sponsorship,[0]CoverMyMeds data on file, Komodo studies 2024 an 11-percentage-point increase in submissions to the plan,[0]ePA program data A/B test 2022 and 2 days faster time-to-pickup with patient notification on approved prior authorizations.[0]PA Notify data for approved prior authorizations, 2024 For denied requests receiving appeal initiation and support, one of every three is approved on average.[0]9. ePA Appeals data, 2023
When you connect your copay program to augment this prior authorization support — whether through an affordability link in a direct-to-patient outcome notice or through automatic copay savings applied at the pharmacy — you now create a seamless pathway to affordable pickup.
The patient's experience: The claim is rejected. The patient may not even know it happened. Behind the scenes, the likelihood of insurance approval is low — perhaps it's early in your brand's launch, or formulary negotiations are ongoing.
The challenge for brands: Traditional approaches would trigger a prior authorization attempt despite low coverage odds, and without embedded support, can introduce delays that often result in patient abandonment or switching to a competitor. Time matters, and every day of delay increases the risk the patient never starts.
The solution: Automatic conversion of rejected claims to paid scripts in real time, before the patient or pharmacist even notices the denial. This can instantly transform rejection into therapy access, with the brand determining the patient cost and number of covered fills.
The flexibility here is strategic. Brands can configure three distinct pathways: convert immediately at rejection for a defined number of fills; convert and simultaneously initiate a prior authorization to attempt insurance coverage for subsequent fills; or pursue prior authorization first and convert only if denied. A traditional copay card program can also support rejected claims as another alternative approach.
In a one-year period between 2024 and 2025, this solution converted more than 6 million rejected patient claims to paid scripts,[0]Denial Conversion bill data Calendar Year August 2024-July 2025 capturing patients who would have otherwise been lost. The power lies in timely intervention — claim rejection auto-conversion fixes the problem before the patient even knows it happened, maximizing patient reach when coverage barriers are high.
Therapy access rarely follows a single path. By embedding brand support directly into a unified access ecosystem, you coordinate solutions across make-or-break decision points within an interwoven system, rather than fragmented programs that address each moment in isolation.
Individually, each solution addresses a specific access barrier. But when you combine copay, prior authorization support, and post-rejection conversion, they become a dynamic system that responds to whatever challenge emerges at the pharmacy.
A commercially insured patient with an approved claim receives on-the-spot affordability support without friction. A prior authorization initiates automatically when a claim is rejected, cutting days off time-to-pickup while keeping your brand visible and connecting to your copay program. A patient facing rejection can be instantly converted to paid while a prior authorization runs in the background for future fills.
This integration matters because therapy access rarely follows a single path. By embedding brand support directly into a unified access ecosystem where 1 million providers, 350+ integrated EHRs, 50,000+ pharmacies, and payers covering 96% of prescription representation already operate, you coordinate solutions across these make-or-break decision points within a single interwoven system — not through fragmented programs that address each moment in isolation.
CoverMyMeds helps patients access therapy more than 111 million times annually[0]Calendar Year 2024; CoverMyMeds data on file, transforming that volume into actionable insights that help brands refine targeting, optimize spend, and respond to evolving access dynamics throughout the product lifecycle. Our specialized Customer Success Teams bring both data and strategic guidance to help your brand navigate complexity, from launch through loss of exclusivity.
Access and affordability challenges will continue to evolve, but the moments where therapy success is determined remain consistent. The question is whether brands approach them with disjointed solutions or with a unified strategy designed to maximize patient reach at every decision point.
Connect with CoverMyMeds to explore how configurable access and affordability solutions can work together to maximize patient starts for your brand. Together, we can design a strategy that turns barriers into therapy access.
