Copay Funds Are Being Misused at the Pharmacy. Now There’s a Way to Stop It in Real Time

Sponsored by ConnectiveRx

In this conversation, Cindy Baksh of ConnectiveRx explores how copay assistance programs—long relied upon to improve patient access and drive utilization—have become both one of pharma’s most powerful commercial tools and one of its most exposed investments. As payer dynamics grow more complex, with the rise of high-deductible plans, accumulators, maximizers, and alternative pricing models, the risk to copay program spend has increased significantly. What was once a relatively straightforward benefit design now requires a more sophisticated and proactive approach to protect gross-to-net performance.

Copay misuse at the pharmacy level is not always intentional. In many cases, it stems from efforts to help patients afford medications. However, regardless of intent, the financial impact remains the same—manufacturer funds may be used outside of program rules, reducing the resources available for patients who need assistance most. With billions of dollars at stake annually, even small inefficiencies can scale into substantial losses.

To address this challenge, ConnectiveRx is shifting the paradigm from retrospective analysis to real-time prevention. Baksh highlights how the company’s ShieldRx solution is designed to intervene at the moment a copay claim is submitted—within the pharmacy workflow—helping to stop inappropriate spend before it occurs. Using multi-dimensional analysis supported by advanced algorithms and AI, the solution evaluates key aspects of each claim to determine whether it aligns with program criteria.

Cindy underscores the importance of evolving copay strategies to match today’s dynamic landscape. A combined approach—leveraging both real-time protection and retrospective insights—can help manufacturers better control costs, strengthen program integrity, and ensure that copay assistance delivers its intended value.