A prescription can be medically right for a patient and still never make it into that person’s hands. One AffirmedRx member experienced that situation when the specific brand of seizure medication she relied on was removed from her plan’s formulary.
Although another medication was available, it was not a safe alternative for her because it could trigger seizures rather than preventing them.
In 2025, Kristin Rice, a Patient Care Advocate at AffirmedRx, spent several weeks identifying pharmacies that could guarantee access to the correct brand. When those options did not resolve the issue, she escalated the case to company leaders and continued working toward a solution.
Rice eventually secured an override, allowing the member to receive the required brand through 2026. Without it, the medication change could have increased the risk of seizures and led to additional medical care, including emergency treatment or hospitalization.
The case highlights an important point for employers: lowering the price of a medication is only part of managing healthcare costs. If members cannot access their prescriptions and stay on treatment, those barriers can lead to avoidable complications and higher costs.
Employers Must Look Beyond the Price of Prescriptions
The 2025 Pulse of the Purchaser survey gathered responses from 324 private and public employers and healthcare purchasers across the United States. For the fifth consecutive year, 99% identified drug prices, hospital prices and high-cost claims as their top affordability concerns.
High drug prices can create a copay a member cannot afford. A covered prescription may still be delayed by prior authorization, which requires additional approval before coverage is provided. Pharmacies may not have the required medication or brand in stock, and members may struggle to find the right pharmacy, mail-order option or assistance program.
Medication adherence is a key link between prescription access and healthcare outcomes.
The Centers for Disease Control and Prevention reports that about one in five new prescriptions are never filled. Among prescriptions that are filled, about half are taken incorrectly. The agency also estimates that nonadherence accounts for $100 billion to $300 billion in direct U.S. healthcare costs each year.
Cost remains one of the most common reasons treatment is interrupted. In 2021, 8.2% of U.S. adults ages 18 to 64 who used prescription medication reported not taking it as directed because of cost. That included delaying a refill, skipping doses or taking less medication than prescribed.
Why Members Should Not Be Messengers
When a claim is rejected, resolving the issue often requires coordination between the provider, pharmacy and pharmacy benefit manager (PBM). Without effective communication among these groups, members may be left to connect the pieces themselves, delaying access to the medications they need.
According to the Agency for Healthcare Research and Quality, care coordination helps reduce fragmentation by ensuring that everyone involved in a patient’s care shares information and works toward the same goal. In pharmacy benefits, that coordination can make the difference between a timely resolution and interrupted treatment.
A member may know that a claim was rejected without understanding why, while the pharmacy may see a rejection code but lack the clinical details needed to resolve it. Meanwhile, the provider may not realize that additional information, an approval or an exception is required before the prescription can be filled.
Effective coordination turns a confusing coverage issue into a manageable next step for the member, ensuring administrative barriers do not become treatment barriers.
AffirmedRx addresses these challenges through its Patient Care Advocate model. Advocates help members navigate pharmacy issues by working directly with providers and pharmacies.
“Proactivity is the keystone holding up the effectiveness of AffirmedRx’s patient-centric model,” the company said. “Patient Care Advocates have real-time access to claims and denials that allows them to resolve issues through coordination with providers and pharmacies before patients arrive at the pharmacy counter.”
A shared cloud-based platform allows advocates to document and track cases, collaborate with other team members and escalate issues when necessary. An advocate may help complete prior authorization requirements, confirm whether a pharmacy has the required medication or identify a lower-cost option when another drug is clinically appropriate.
With access to more than 67,000 retail pharmacies, along with mail-order and specialty pharmacy networks, PCAs can help members explore where a prescription may be available or cost less. They may also connect members with employer-sponsored resources such as copay assistance, mental health services and chronic condition support programs.
Understanding the Difference Between Engagement and Resolution
Member engagement is often measured through calls, portal visits or survey responses. While these metrics show that a member interacted with a benefit, they do not show whether that interaction helped them obtain medication, stay on treatment or avoid a larger healthcare issue.
Employers and plan sponsors gain more useful insight by looking at what happened after the interaction.
Did the member understand why the claim failed? Did the provider receive the information needed to move the request forward? Was the pharmacy able to fill the prescription? If the original medication was unavailable, did the member receive a clinically appropriate alternative?
These outcomes matter because a pharmacy benefit can only manage costs effectively when members can access and use the care it provides. Benefits leaders should consider whether their PBM can identify barriers early, provide proactive support, escalate complex cases and remain involved until the issue is resolved.
The Centers for Disease Control and Prevention cites education, refill support, provider communication and follow-up as strategies that may improve medication adherence. Their usefulness, however, depends on the reason treatment is at risk.
A refill reminder may help someone who forgot to request medication, but it will not fix an incomplete prior authorization, a coverage problem or an unaffordable out-of-pocket cost.
Effective member engagement depends on a PBM’s ability to identify the barrier and provide the correct solution. That might mean helping one member find a lower-cost pharmacy or coordinating with a provider and pharmacy to resolve an approval issue for another.
AffirmedRx evaluates both the financial barrier and the member’s experience while an issue is being resolved.
“We analyze out-of-pocket costs for members that can often be a barrier to access or continuity of care,” the company said. “We conduct surveys to assess the member experience both at the organizational and individual level.”
Those measures give employers more context than call volume or portal activity alone. They can show whether cost is interfering with continued treatment and whether members feel supported as they work through a problem.
From Cost Savings to Member Value
Employers need to understand not only what they are spending on medications, but how those decisions are affecting the member experience. Claim-level data offers a clearer view of the full cost of care, including medication price, member out-of-pocket responsibility, manufacturer price concessions and the final amount paid by the plan.
AffirmedRx provides that transparency through a fixed administrative fee model. It passes manufacturer price concessions to clients and does not use spread pricing, where a PBM charges a health plan more than it reimburses a pharmacy and keeps the difference.
The company also provides claim-level data and considers clinical appropriateness alongside cost when making formulary recommendations, while employers and health plans retain final authority over formulary decisions.
For benefits leaders, transparency matters because financial decisions directly affect the member experience. Claim-level visibility helps employers determine whether lower-cost options are truly creating value or unintentionally creating barriers to treatment.
AffirmedRx reviews often highlight the company’s status as a Public Benefit Corporation, which distinguishes it from traditional PBMs. Since becoming a PBC in 2022, its leaders have been required to consider the impact of business decisions on stakeholders, including members and clients, alongside financial performance.
“AffirmedRx’s patient-centric model is less an innovation than it is a re-focusing of what truly matters – the health of the plan members and their experience in achieving and sustaining healthy lives,” the company said.
As AffirmedRx grows, expanding the Patient Care Advocacy team remains a priority. The company’s long-term goal is to identify and resolve access problems before members are even aware of them.
For the member who relied on a specific seizure medication, the value of the benefit was not measured by a rebate calculation or a lower drug cost. It was measured by maintaining access to the medication she needed through 2026.
That is the standard benefits leaders can bring to their own pharmacy strategies. Managing prescription spending remains important, but the strongest cost strategies also help members understand their benefits, overcome barriers and receive the treatment their providers prescribe.
