FAQ: How Payers Can Ease Drug Cost Burdens for Patients, Physicians

Medicare Advantage (MA) premiums are projected to fall more than 16% from 2026 to 2027, with average prescription drug premiums in MA projected to drop 38%.¹ Yet a recent survey found that 96% of physicians have had a patient stop taking a medication because of cost without telling them first.²

While the 2 findings are neither causally linked nor correlated, the RazorMetrics survey of 104 physicians speaks to patients' ultimate and longstanding health care concern: cost.² The same survey found that 84% of practices field 5 or more patient calls a week about high-cost prescriptions, and 2 out of 3 practices spend 5 or more hours every week resolving medication cost issues after a prescription has been written.²

Even with policies like the Global Benchmark for Efficient Drug Pricing (GLOBE) Model, aimed at delivering lower drug prices for Medicare beneficiaries, many still struggle to afford medication that could preserve their overall quality of life.³ Skipping a necessary medication due to cost can also have downstream effects on patients' health and overall health care spending should their condition worsen in its absence.

“It's a heartbreaking scenario, right? A patient doesn't take the med. They go in with a hypertensive emergency, and they get a $50,000 bill, and they simply can't afford it,” Siva Mohan, MD, a board-certified general and interventional cardiologist and cofounder and chief medical officer of RazorMetrics, said in an interview with The American Journal of Managed Care^® (AJMC^®). “They can't make the payments, even if they have a payment plan.”

For payers and providers looking to manage high drug costs for patients, here are 4 frequently asked questions.

When a Patient Abandons a Prescription Over Cost, Who Bears the Brunt of the Consequences?

Nearly 30% of Americans say they haven't taken their medication as prescribed due to high drug prices, according to a May 2024 American Hospital Association (AHA) blog post.⁴ The AHA also cited an estimate that more than 1.1 million Medicare patients could die over the next decade because they can't afford their prescribed medications.⁴

When patients skip a necessary medication, Mohan said, they often bear the brunt of the downstream effects on quality of life, health, and cost.

“We always think of this as the patient in the middle of everything, and the patient, somehow, will bear the brunt of that. Whether it's from an outcome perspective, they'll do poorly. Whether it's from a productivity perspective or professionally, they won't be as productive. Or even just on a social level,” he explained. “In any way, it'll affect the patient if they're not taking the medications that they prescribed. It's also cumulative over long term.”

How Are Policy Makers Targeting Drug Costs, and Where Does Prior Authorization Fit In?

CMS has announced multiple initiatives in the last year that target overall health care spending and, more specifically, high prescription drug costs. The GLOBE Model, finalized September 30, 2026, will test an alternative way to calculate rebates under the Medicare Part B Drug Inflation Rebate Program, using an international benchmark, when it launches January 1, 2027.³

Congress also introduced companion bills in the House and Senate in late September 2026 to make biosimilar development and product launches more predictable. The Biosimilars Access and Affordability Act (HR 10628 and S 5571) would automatically delay Medicare price negotiation for a reference biologic facing biosimilar competition.⁵

The RazorMetrics survey also asked physicians how often they receive outreach from pharmacy benefit managers (PBMs) or plan sponsors about high-cost drugs. About 71% said they hear from PBMs and plan sponsors at least occasionally, but only 34.6% review and act on that outreach, while 44% review it but rarely change anything.²

Nearly half (49%) said fewer interruptions to their workflow would make that outreach more useful. In addition, 42% of practices manage more than 30 prior authorization (PA) requests a week, and 48% of physicians said 50% to 75% of their PA requests are eventually approved.²

“I think [PAs] originated for a good reason, but I think it's become a kind of charged topic,” Mohan said. “Patients hate it because it creates delays, and they're waiting for the insurance company to approve it, and maybe they don't get the medication that they think they should be getting for [their] condition.”

From the clinical side, the friction is similar. Mohan said physicians are trying to do what's best for their patients, but not knowing whether a PA will be approved creates friction and opacity, particularly because the process is tied to rebate and payment structures within a complex system.

“Hopefully there's progress here, and there's more of a kind of transparent system rather than not. But bear in mind, the alternative is to not have a PA system and have a very narrow formulary,” he said. “…So, creating more clarity on how it happens for us as clinicians is easier, and also patients having them understand why medications are PA and what that process is…I think would be helpful.”

How Can Education Help Physicians and Patients Feel Confident Switching to Biosimilars?

Biosimilars are uniquely positioned within health care to be a cost-saving alternative for numerous drugs across a wide spread of diseases and conditions. Although development is lagging, numerous policies have been enacted or introduced to simplify development and bring products to market, making them more accessible to consumers.⁵

And while numerous biosimilars are coming to market, Mohan said they can be a harder switch because, due to the conditions they treat, patients are “more attached emotionally to the medication.”

He also emphasized patient and provider education on biosimilars. In the RazorMetrics survey, 44% of physicians said they were somewhat confident prescribing biosimilars, and 34% cited lack of clinical familiarity as their biggest barrier to prescribing them more often.²

“Our job [at RazorMetrics] is to educate the physician often to let them know, ‘Hey, here are the options, they're all FDA approved [and] here are the indications,’ because there's a lot of information overload, and there are times where maybe a physician doesn't really understand clearly if that medication, even though some party is trying to switch it, is the right switch,” Mohan explained.

What Metrics Should Payers and Providers Track to Know Whether Affordability Efforts Are Working?

Mohan said avoided emergency department visits are difficult to measure unless a patient visits frequently, but adherence can be tracked, and small changes can improve it, such as filling all of a patient's prescriptions at 1 pharmacy or moving certain medications to 90-day supplies when the cost is at least equivalent.

“It's really about…making sure the physician has all the right information, high-fidelity information about all the medications the patient has been taking and is taking, and what all those scripts look like,” he said.

He added that physician time recovered is an often-overlooked measure. “If we're wasting time trying to figure out…what medications the patient's on…something else is going to be given,” Mohan said.

References

1. Medicare Advantage and Medicare prescription drug programs expected to remain stable in 2027. News release. CMS. September 28, 2026. Accessed October 15, 2026. https://www.cms.gov/newsroom/press-releases/medicare-advantage-medicare-prescription-drug-programs-expected-remain-stable-2027

2. Physician drug cost survey 2026. RazorMetrics. Accessed October 15, 2026. https://razormetrics.com/wp-content/uploads/2026/09/RazorMetrics-Physician-Drug-Cost-Survey-2026.pdf

3. Grossi G. CMS finalizes mandatory GLOBE model to test lower Part B drug costs. AJMC. October 1, 2026. Accessed October 15, 2026. https://www.ajmc.com/view/cms-finalizes-mandatory-globe-model-to-test-lower-part-b-drug-costs

4. Krishnamurthy B, Parikh M. Drug prices and shortages jeopardize patient access to quality hospital care. American Hospital Association. May 22, 2024. Accessed October 15, 2026. https://www.aha.org/news/blog/2024-05-22-drug-prices-and-shortages-jeopardize-patient-access-quality-hospital-care

5. McCrear S. Biosimilar bills would automate Medicare negotiation delays. Center for Biosimilars. October 12, 2026. Accessed October 16, 2026. https://www.centerforbiosimilars.com/view/biosimilar-bills-would-automate-medicare-negotiation-delays