Blueprint for the Future: Designing Scalable Copay Programs in a Rapidly Evolving Landscape

At this year’s Informa Connect Copay, Reimbursement and Access Congress, I had the opportunity to dive deep into one of the most pressing challenges facing biopharma manufacturers today: how to build copay programs that are not only compliant and scalable but also aligned with gross-to-net (GTN) strategies, and most importantly, centered around the patient experience.

Our industry is experiencing unprecedent change. Policy reforms and rising patient expectations are converging to reshape the way we think about medication access. Legislation, like the Inflation Reduction Act (IRA) and Most-Favored Nation (MFN) Pricing, is accelerating GTN compression. Meanwhile, commercial plans are deploying increasingly sophisticated accumulator and maximizer strategies, challenging the effectiveness of traditional copay models.

To truly support patients, we must rethink how affordability solutions are designed and delivered. That means meeting patients where they are, at every step of their treatment journey with solutions that are intuitive, integrated and impactful.

In this environment, simply standing up a copay program isn’t enough. We need to design holistic systems that can adapt to our complex and evolving access and affordability landscape. The goal is to establish fully connected programs that support patients from prescription to dispense. Here are four guiding principles I shared to help biopharma leaders navigate this new terrain.

Four Pillars for Resilient Copay Strategy

1. Scalability Means Flexibility for Patients and Brands

Scalability is about reach and adaptability. Today, many programs only trigger alerts when a claim is approved or rejected, leaving patients unsure of their options and without support. Barriers can arise before approval, during the prior authorization (PA) process and even after the first fill. To truly help patients, we need to proactively deliver solutions at the moment of need. At CoverMyMeds, we’ve seen how modular designs allow manufacturers to tailor components to meet specific brand goals. Some pathways to consider in program design include:

• Automatic pharmacy counter offers where support can be applied instantly.
• Alternative payment method or direct‑to‑patient cash pay options.
• Accounting for access along with affordability, including PA and benefit pathways.
• Patient communication: Consent‑based outreach allows trusted voices to deliver messages that are triggered throughout the journey.

We already use modularity and targeting inside copay programs; the next step is to apply those same ideas across the entire access and affordability collection, so each patient journey is targeted.

2. Safeguarding Is Now a Strategic Imperative

With accumulator and maximizer tactics becoming more prevalent, compliance has taken on a new level of importance, protecting patients and preserving program integrity. Our Government Plan Exclusion (GPE) logic helps identify federal plans using BIN and PCN data, ensuring copay assistance is applied appropriately. We build rules to be dynamic, not static checklists, so defenses can evolve as quickly as the environment does.

3. Automation and AI Must Work in Tandem with Clinical Judgment

One of the key points I emphasized during the session was the distinction between automation and artificial intelligence (AI). Automation ensures the right next step for every patient, every time. Examples to consider for your program include:

• Pre-populated PAs that trigger when a claim rejects and criteria are known, routing to the right party with the right evidence the first time.
• Auto-completed enrollment using available information, so staff only handle what’s missing.
• Smart triggers for coverage changes, refill patterns or sudden out-of-pocket cost spikes.
• Proactive, consented patient nudges to keep the path from prescription to first fill short and clear.

The point isn’t to remove care teams; it’s to reserve clinicians for the moments that matter with patients. AI and automation should be implemented thoughtfully and at scale, with cross-functional collaboration and a human-in-the-loop approach. AI can help surface insights, but clinical judgment must remain central, especially when supporting patients with complex therapies or vulnerable conditions. Automation helps care teams identify accumulator exposure, flag GTN leakage and recommend program adjustments, but humans remain in control. For deeper insights, check out our podcast, “Balancing AI and Clinical Expertise.”

The future lies in a fully integrated operating system that unites access and affordability, coordinated by a single intelligence to orchestrate the next best action. This approach enables shared identity, common events, and unified outcomes, moving us from simply reporting to actively guiding. Integration enhances visibility; visibility drives automation; and automation delivers real-time guidance for patients.

Looking Ahead

If we continue to operate reactively, we risk leaving patients behind and missing opportunities to drive real, lasting change. The future demands that we move from isolated to a connected, proactive system. That’s why visibility, automation and integration aren’t just buzzwords, but part of our everyday planning process.

• Visibility is foundational: Visibility is the connective tissue of a modern copay program. If we can’t see the entire patient journey, we can’t guide it. Visibility means understanding where every dollar goes, where fragmentation appears and where opportunities for improvement exist. It’s about having real-time data that empowers us to act, not just observe.

• Automation is no longer optional: Automation is what transforms visibility into action. The complexity of today’s environment demands speed and precision. Automation frees up time to focus on what matters most: the moments that require human judgment, empathy and expertise. It also helps reduce errors, accelerate access and ensure that help arrives when and where it’s needed for the patient.

• Integration is where impact compounds: Integration connects every part of the journey, enabling us to orchestrate the next best action for every patient. The impact is exponential: when systems work together, every improvement builds on the last, creating a cycle of continuous progress.

This is the roadmap for the future of copay programs. A future where every stakeholder is connected, every patient is supported, and every action moves us closer to shared goals. Learn more about copay strategies, here.