At the Pharmacy, Affordability Connects Policy, Plans, and Patients

A prescription can be written, covered, and approved and still never reach a patient. At the Academy of Managed Care Pharmacy Nexus 2026 meeting, in the session “The Last Mile at Point-of-Sale: Why the Pharmacy Counter Decides Everything Policy and Plan Design Set in Motion,” leaders from pharmacy operations, policy, and health technology showed how coverage and plan-design decisions made well before a patient reaches the pharmacy counter can fail, leaving a prescription unfilled.¹

They anchored their discussion in a hypothetical case: a patient with a new prescription for their diabetes visits a pharmacy in January. The doctor wrote it, the plan covered it, and the pharmacy billed the insurer. The first fill was quoted at the full deductible price, but 3 days later the claim was reversed. Michael T. Einodshofer, RPh, MBA, CEO, specialty, frontier and home delivery, Optum Rx, moderated this discussion. He was joined by John M. O’Brien, PharmD, MPH, president and CEO of the National Pharmaceutical Council, and Anurati Mathur, co-founder and CEO of Sempre Health.

Coverage Is Not the Same as Cost

Einodshofer said 3 systems, or layers, decide if a prescription is filled, and they are “almost never in the same room.” These systems are policy and evidence, pharmacy operations and affordability, and the member at the counter. He drew a fine line between coverage and price.

“Formulary is what’s going to be covered. Benefit design is what you’re going to pay for it, and they’re both really important, and they work together,” he said. The consequences are measurable.

One in 3 patients report not taking medications as prescribed,² and cost-related nonadherence is tied to 15% to 22% higher mortality among adults with chronic disease.³ Further, for adults with Medicare Advantage prescription drug coverage, missing 1 or more adherence measures has been equated with 14% to 20% higher monthly medical costs per person.⁴ IQVIA data from its Use of Medicine in the U.S series also show abandonment of new prescriptions increasing from 5% at $0 to 69% when the price jumps above $250.

The Policy View

O’Brien said his lens never changes. “What I’m always thinking about most is how it’s going to effect the patient and the pharmacy,” he said, referencing a systematic review in which 84% of published analyses tied higher cost sharing to worse adherence⁵ and data showing that treatment persistence was 62% under standard benefits but 54% under co-pay accumulator programs.⁶ He credited the Inflation Reduction Act for the patients it helped most.

“Despite these shortcomings and the unintended consequences of that law,” O’Brien said, “I always said that if you are one of the patients who was paying 5% of your high-cost prescriptions every month, this law was a godsend for you.”

Among the policy levers he singled out were Medicare’s payment smoothing option. “The ability to smooth that out over the course of the year, that is a woefully underutilized aspect of the Medicare Part D redesign,” he added. However, the more serious problem is the deductible.

“Prescription medicines are the only health care good or service where what a patient pays out of pocket in the deductible is based on the billed amount of list price and not the allowed amount or net price,” he explained.

The Operations View

Einodshofer showed how 6 decisions—list price, plan design, network and channel, what the members owes, third-party assistance, and accumulator rules—made by 6 different teams, produce the one number a member ever sees: their out-of-pocket share. He explained that formulary placement sets eligibility and relative cost, but not the patient’s actual cost. At Optum Rx’s specialty pharmacies, staff bring up affordability early in onboarding. Cancellations fell 89% after the pharmacies switched to this proactive approach addressing unaffordability.

“We do our part to make sure we use all of the tools available to make sure the patients walks away with their medication,” Einodshofer said. The results bear this out. About 4 in 5 patients pay less than $25, he said, and 3 in 4 pay nothing. However, support is getting harder to find, he highlighted.

Of foundation grants, he said, “Ten years ago they would be open for weeks. Now grants will open and close in a matter of minutes because there’s so much demand out there.” Even so, patients need help. As an example, he noted that with a $10,000 drug and 20% co-insurance, a January fill can mean $2000 at the pharmacy counter.

“A patient can’t navigate this on their own,” he said.

The Patient View

Mathur said population-level levers exclude the individual patient. Co-pay cards, manufacturer assistance, accumulator programs, and $0 cost sharing each have a place, she said, “but the effectiveness of any intervention comes down to matching the right patient in the right circumstance with the right tool.” Cards, she noted, put the burden on the patients to find them. As she stated, “The card doesn’t know anything about you before you download it and take it to the pharmacy counter.”

She asked, “Where could you actually adapt and bring precision to affordability?” Her answer was to pair a plan-sponsored incentive with text refill reminders.

Mathur cited 2 evaluations that supported this proposal. In a UPMC Health Plan study, days adherent rose 48% among users of antiplatelet medications and 30% among users of anticoagulants, and emergency visits dropped 16%. In a Blue Shield of California analysis of 31,304 eligible members, adherence rose among enrolled members and fell among nonenrolled but eligible members.

A third study, which Sempre conducted with Mayo Clinic, showed that patients who received discounts on branded drugs through the company’s program resulted in an approximate 9% increase in adherence to generic drugs the program did not target, Mathur explained. “When you free up dollars in a patient’s pocket, they can be spent on other necessities,” she said.

Overall, she had 3 lessons for anyone designing benefits: reach members before the counter, tie price to behavior, and recognize that engagement does real work. Price alone is not the lever, she concluded. “Engagement is a means to an end,” she emphasized.

Einodshofer closed with these key takeaways for managed care pharmacists:

1. Look at policy, plan operations, and patients programs together, because a prescription’s fate depends on how they interact
2. Understand how formulary, rebate, network, and accumulator rules interact at the pharmacy counter
3. Use the peer-reviewed evidence that now exists to assess affordability programs

References

1. Einodshofer MT, O’Brien JM, Mathur A. The last mile at point-of-sale: why the pharmacy counter decides everything policy and plan design set in motion. Presented at: AMCP Nexus 2026; October 26-29, 2026; San Diego, CA.
2. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-14. doi:10.4065/mcp.2010.0575
3. Van Alsten SC, Harris JK. Cost-related nonadherence and mortality in patients with chronic disease: a multiyear investigation, National Health Interview Survey, 2000-2014. Prev Chronic Dis. 2020;17:E151. doi:10.5888/pcd17.200244
4. Poonawalla IB, Chung L, Shetler S, Pearce H, Dixon, SW, Racsa P. Medication adherence star ratings measures, health care resource utilization, and cost. Am J Manag Care. 2024;30(5):210-217. doi:10.37765/ajmc.2024.89538
5. Fusco N, Sils B, Graff JS, Kistler K, Ruiz K. Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: a systematic literature review. J Manag Care Spec Pharm. 2023;29(1):4-16. doi:10.18553/jmcp.2022.21270
6. Henderson R, Motyka J. Accumulator and maximizer impact on medication adherence and health services usage. Presented at: AMCP 2024; April 15-18, 2024; New Orleans, LA. Accessed October 27, 2026. https://amcpannual.org/sites/default/files/2024-04/2024%20April%20JMCP%20Poster%20Abstract%20Supplement%20-%20FINAL.pdf
7. Peasah SK, Liu Y, Krohe S, et al. Assessing the impact of a financial incentive and refill reminder program on medication adherence and costs. J Manag Care Spec Pharm. 2024;30(1):43-51. doi:10.18553/jmcp.2024.30.1.43
8. Shaw G. Proactive copay savings linked to better adherence in 2 health plan studies. Specialty Pharmacy Continuum. October 27, 2026. Accessed October 27, 2026. https://www.specialtypharmacycontinuum.com/Online-First/Article/10-26/Copay-Savings-Linked-to-Better-Adherence-in-Health-Plans/81989