A Better January for Patient Support Starts at the Prescriber’s Office
When the office hears about a January rejection right away, the patient reaches your support program sooner and with the right paperwork.
It is the first week of January. Alex, who has done well on their therapy for two years, goes to the local pharmacy for a refill. Their employer changed insurers in the new year. The pharmacy sends the prescription back because the new plan wants a prior authorization the old one never asked for. Alex goes home without it. Their coverage worked all last year, so nobody ever had a reason to enroll them in the manufacturer’s patient support program—and the program does not know they exist.
Alex assumes the office is handling it. The office does not know either, because no one told it. When Alex calls at the end of the week, the coordinator starts a new plan’s authorization from the beginning, for a patient who is running short. Nobody mentions the copay program, because nobody in the office connects Alex to it.
All of it could have been handled the day the pharmacy sent the prescription back.
What changes on January 1, 2027
Payers and employers set the January coverage and benefit conditions, and patient support teams don’t always see them ahead of January 1. For the 2027 plan year, some of those conditions are new. The Medicare Part D deductible rises to $700, from $615.[1] The federal subsidy that held down stand-alone Part D premiums ends with 2026, and the number of drug plans open to the average beneficiary has already fallen from 30 to 14 since 2021—so more Medicare patients will be choosing a new plan this fall.[2] And adults covered under Medicaid expansion move to eligibility checks every six months for renewals scheduled on or after December 31, 2026, so for a chunk of that population, reverification stops being a once-a-year job.[3] On the commercial side, 26 states now restrict copay accumulators, which together cover about a sixth of commercial lives; in the rest of the market, most plan designs have an accumulator or maximizer available and about 4 in 10 use one.[4,5]
What a cost change does to a refill is on record. In one study of continuing patients, January abandonment was 3% when the patient’s cost had not changed from the last fill of the prior year and 11% to 12% when it had gone up by more than $50.[6]
We see it in our own network. Across several specialty brands we audited this year, every one saw its rejection rate rise from December to January, by a median of 9 points, and its dispense rate fall by about 10. Patients who didn’t get their prescription rose by roughly a third. February and March recovered only part of the way, and the first quarter as a whole ran about 6 points below the rest of the year. In one audit we conducted, we saw the average patient cost per fill nearly triple between December and January; and the number of abandoned prescriptions reached the annual high in January.
By October, most patient support leads have already decided whether continuing patients on the copay program renew automatically or re-enroll, whether the bridge program will take a continuing patient whose new plan wants a prior authorization, which version of the enrollment form the hub will accept, and how the hub staffs the first two weeks of the year.[7] That work is why most enrolled patients get through the reset without missing a dose.
Reverification covers the patients the program already knows
Reverification is built on the program’s own files: the patients enrolled, on the coverage the hub last confirmed. Everything the program reports in January, from time to first fill to enrollment conversion, is measured on those patients and no one else.
A patient support program can see some of January coming in the fall: which enrolled patients have an authorization that ends December 31 and which plans have published new criteria for the coming year. The rest cannot be known until the first January prescription is sent back: the patient’s new member number, their new pharmacy benefit manager, whether the new plan honors last year’s approval, and the patient who was never enrolled. A handful of states—among them Tennessee, Nebraska, and Indiana—now require a new plan to honor an existing approval for the first two to three months,[8,9] and the large insurers have pledged 90 days since January 2026.[10] Everywhere else it starts over. The never-enrolled patient is who the copay program and the hub were built for, and Alex is not in any report the support program runs.
The prescriber’s office is often the last to hear
The office usually learns that a prescription needs authorization after the fact, when the pharmacy or the patient calls; few offices learn at the point of prescribing.[11] What the pharmacy sends back is often a rejection code with no reason the office can act on, and it arrives with the rest of the day’s paperwork.
When the office hears right away, the patient still has medication on hand, the chart notes are easy to pull, and the authorization gets started. When it hears weeks later, the patient has gone without, the physician wants the problem resolved, and a covered alternative is the fastest way to resolve it. Only 21% of physicians say they always appeal a denial, and about half of those who do not appeal the denial say it is because the patient cannot wait for an answer.[12] In January, when the office’s own paperwork is at its yearly peak, that choice gets made sooner. Enrolling Alex earlier would have meant a physician’s signature and a diagnosis on a form for a patient who previously had no problem.
What a patient support lead can decide and put in place this fall
Ask the hub for last January by week: where each case came from, how many enrollments arrived incomplete, and how long the patient had already been waiting when the program first heard of them. Compare it with October. That gap is the number to shorten.
Put the program where the office will find it before benefits reset and plans change. What a coordinator keeps at their desk is one page, dated for the coming year, with the current enrollment form, the hub phone number, the copay renewal instructions, and one line on what to do when the pharmacy sends a prescription back. It reaches the office the ways the brand already does: field reimbursement visits, the brand’s Web site, and notifications. Ask the hub to accept last year’s form through February, because offices will fax it all January.
Decide in October, while compliance sign-off is still possible, whether the bridge and quick-start programs will take a continuing patient whose new plan wants a prior authorization. Most are written for patients starting the therapy, and Alex has been on it for two years.
Then decide how the office will hear that a prescription came back, why, and where to send the patient, when it happens. For enrolled patients, the hub carries part of that. For the patient the program has never met, the office is the only place a patient like Alex can be reached. The rejection reason, in the office’s hands, is also the first clean read on whether the plan changed or the paperwork did.
ReCaptRx is how our clients do that last step: a notification to the prescriber’s office when the prescription is rejected, reversed, or not picked up, carrying the reason and the brand’s own patient support resources. It works alongside the hub, the copay program, and the field; and every notification points the office to your program.
References
Centers for Medicare & Medicaid Services. Announcement of calendar year 2027 Medicare Advantage capitation rates and Part C and Part D payment policies. April 6, 2026. Accessed September 25, 2026. https://www.cms.gov/files/document/2027-announcement.pdf
Centers for Medicare & Medicaid Services. Medicare Part D 2027 national average monthly bid amount information. July 28, 2026. Accessed September 25, 2026. https://www.cms.gov/newsroom/fact-sheets/medicare-part-d-2027-national-average-monthly-bid-amount-information
KFF. Health provisions in the 2025 federal budget reconciliation law. August 22, 2025. Accessed September 25, 2026. https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law
Avalere Health. State copay accumulator bans now affect at least 17% of commercial lives. December 10, 2025. Accessed September 25, 2026. https://advisory.avalerehealth.com/insights/state-copay-accumulator-bans-now-affect-at-least-17-of-commercial-lives
Fein AJ. Copay accumulators and maximizers in 2025: popular, profitable, and problematic. Drug Channels. February 10, 2026. Accessed September 25, 2026. https://www.drugchannels.net/2026/02/copay-accumulators-and-maximizers-in.html
IMS Institute for Healthcare Informatics. Emergence and impact of pharmacy deductibles: implications for patients in commercial health plans. September 2015. Accessed September 25, 2026. https://www.iqvia.com/-/media/iqvia/pdfs/institute-reports/emergence-and-impact-of-pharmacy-deductibles.pdf
Marsh J. Planning for the surge: taking a proactive approach to benefits re-verification season. Pharmaceutical Commerce. June 1, 2020. Accessed September 25, 2026. https://www.pharmaceuticalcommerce.com/view/planning-for-the-surge-taking-a-proactive-approach-to-benefits-re-verification-season
Sullivan L, Celik Z, Killelea A. Prior authorization reform heats up. Georgetown University Center on Health Insurance Reforms. December 17, 2025. Accessed September 25, 2026. https://chir.georgetown.edu/prior-authorization-reform-heats-up
Henry TA. Fixing prior auth: we must ensure continuity of care. American Medical Association. April 24, 2025. Accessed September 25, 2026. https://www.ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-we-must-ensure-continuity-care
AHIP, Blue Cross Blue Shield Association. Prior authorization industry initiative: industry progress. Presentation to: the National Association of Insurance Commissioners (NAIC); June 29, 2026. Accessed September 25, 2026. https://content.naic.org/sites/default/files/call_materials/priorauth-industry-reform-initiative-naic-rftf-6-29-26.pdf
CoverMyMeds. Electronic prior authorization. Accessed September 25, 2026. https://insights.covermymeds.com/medication-access-report/2020/electronic-prior-authorization
American Medical Association. 2025 prior authorization physician survey. Accessed September 25, 2026. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
