Rejection, Rejection, Rejection
Ask any pharmacist who has worked the opening shift on January 1st what the screen looks like, and you’ll get the same answer: rejection, rejection, rejection, rejection.
It’s not a system glitch. It’s the calendar. Two to three out of every ten patients change benefits year over year – a new employer, a spouse’s plan, a formulary shakeup. On the manufacturer side, they call it “welcome season.” At the pharmacy counter, it looks more like a pileup.
That scene opened our latest episode of The GTN Edge Podcast, where Gerard Rivera and Stephen Hom sat down with Dan Bench, RIS Rx’s new VP of Commercial Solutions and a fellow PharmD with twenty years across retail, specialty pharmacy, and the manufacturer side. The episode is titled “2027 Is Already Here” for a reason. The question Dan kept returning to was simple: are you ready?
Because you can’t think about a patient on December 31st the same way you think about that patient on January 1st.
The Sticker Shock Spiral
Here’s what the new year looks like from the patient’s side. Premiums went up, so they opted into the high-deductible plan – or got moved into one with a maximizer or accumulator built in. Then mid-January, the pharmacy calls: the medication is going to cost far more than they expected. Sometimes it’s a $5,000 copay that, with the right benefit properly applied, should have been zero.
Often, the fix is a single phone call and a little education. But if that call happens after the surprise instead of before it, you’ve already lost something: the patient’s confidence, the provider’s patience (they’re the ones fielding the angry calls), and, at scale, your call center’s capacity.
As Dan put it on the episode, an informed patient is a more adherent, more persistent patient. Expectation-setting is more than just good communication – it’s an adherence strategy.
2026 Taught Us Something: The Tactics Now Adapt
One lesson from this year that carries into the next: PBMs are enforcing counter-tactics, and the landscape shifts faster than a quarterly business review can catch. The team’s benchmark questions for any brand evaluating its current setup:
- Are you finding what you should be finding? At enrollment, roughly two to three of every ten patients should be identified as maximizer-impacted and another two to three as accumulator-impacted. If your at-enrollment solution isn’t holding those percentages, the gap isn’t in the market. It’s in the solution.
- How fast can your platform change? If a PBM algorithm shifts and updating your business rules takes weeks or months instead of being self-serve, that lag is measured in millions. Patients enroll 24/7.
- Are you auditing yourself daily? The north star is average cost per claim. If it isn’t moving the way your program adjustments say it should, something is wrong. And finding out a quarter later is finding out too late.
And this pressure isn’t confined to specialty. With more affordability programs than ever across retail brands — and pharmacy economics tightening to the point of record closures — copay funds sitting in a largely ungoverned space are an increasingly tempting way to make up the spread.
The 2027 Playbook: Three Moves Before the Ball Drops
The heart of the episode is a practical pre-season playbook, and it comes down to three moves:
1. Segment before reverification. Scan your book of business before the new year and pre-tag every patient. If you know who your maximizer patients are in December, you can roll them forward with confidence and let a catch-all mechanism grab the two or three in ten whose benefits actually change. A small subset of patients you don’t catch early can blow your GTN budget.
2. Close the FTE gap before it opens. Even with the best programs in the industry, reducing dollars on a card generates inbound calls. We’ve seen what happens when a manufacturer re-verifies only a cohort of its population to save upfront budget: an overwhelming call surge that no amount of rapid hiring can absorb. Re-verifying everyone up front often costs less than the OPEX explosion that follows – and gives patients a far better experience.
3. Reach out before they call you. Watch the claims daily. A hundred patients billed-and-reversed at the pharmacy is not a statistic; it’s a proactive outreach list. Call them before the confusion becomes an escalation, and most of those patients convert.
No Patient Left Behind
The episode closes where every conversation between three pharmacists eventually lands: the patient in the middle of the ecosystem. Market access, patient services, copay, hub – each holds a piece of the puzzle, and the data between them is siloed. 2027 will reward the brands that connect those pieces before welcome season, not after.
The rejections queue on January 1st is not a surprise. It’s on the calendar.
If you’re planning your reverification strategy and want to segment your patient population before January 1, reach out to Stephen Hom at stephen@risrx.com, or get your GTN assessment.
