April 16, 2020

COVID-19 and Its Impact on Market Access (Payers and Organized Providers)

Man making video call

Executive Summary
The COVID-19 pandemic has triggered immediate responses and unforeseen challenges for payers and health systems across the United States. These changes create new opportunities for pharmaceutical manufacturers to enhance their existing payer relationships while also delivering for healthcare providers (HCPs) and patients faced with navigating their new access and reimbursement realities.

Health plans, pharmacy benefits managers (PBMs) and health systems have worked quickly to amend benefits and processes to address urgent member/patient and HCP needs, including:

  • waiving member cost sharing, including co-pays, coinsurance, and deductibles for diagnostic testing
  • encouraging virtual visits by identifying network physicians who participate in telemedicine, and creating new reimbursement codes for telemedicine appointments
  • adding new reimbursement codes to pay for new services while enabling provisions for early prescription refills
  • encouraging the use of pharmacy delivery services for 90-day refills of chronic medications, and waiving charges for home delivery of prescriptions

During the COVID-19 pandemic — and in its aftermath — market-access and brand marketers need to embrace the tenets of the Triple Aim and focus on improving patient experiences, reducing the per-capita costs of healthcare, and improving the health of populations overall. For this to happen, it’s critical that strategic and tactical options be considered through the lens of patients, payers, and providers.

Triple aim graph

The New Market Access Reality Is a Virtual One
It’s difficult to predict what the “new normal” will look like once the pandemic is contained, but in the short term, health plans, PBMs, and health systems are likely to be open to partnerships with biopharma manufacturers. Such partnerships can assist in effectively managing high-risk patient populations with underlying diseases such as respiratory, cardiovascular, or autoimmune conditions, or cancer. Maximizing this opportunity will require closer collaboration between market-access marketers and their professional and consumer brand teams to ensure message continuity and resource optimization. Specific opportunities and actions that can be taken include:

Opportunity Actions
Develop timely and relevant resources. • Build COVID-19-specific platforms with content focused on managing high-risk patient populations aligned with your organization’s portfolio of treatments.


• Create digital-first resources for payers and organized providers that address business and population health implications and needs.

• Deliver turnkey, unbranded and branded treatment resources with consideration for COVID-19 implications to engage payer and health system case managers, which can also be used with networked providers and members.

Tip: Engage brand team colleagues to determine if approved content already exists that can be quickly customized.

Opportunity  Actions
Embrace multichannel marketing. • Launch MCM campaign to leverage heightened interest in COVID-19 to engage organized provider customers and to generate an opportunity for phone or video calls with account managers.


• Extend account executive impact through non-personal solutions to address payers’ immediate information and resource needs.

• Share content (via CRM, brand.com, or patient support program site [“PSP.com”]) with HCPs, patients, and caregivers about changes in coverage being instituted by large payers, and point to PSP.com or payer websites.

Tip: Engage digital marketing centers of excellence to explore use of existing MCM infrastructure.

Opportunity Actions
Ensure favorable product access and supply chain availability. • Create supportive materials that make the case for less-restrictive formulary designs for at-risk patient populations.


• Negotiate less-restrictive formulary controls to eliminate access barriers for branded products, especially in key therapeutic categories that face generic product shortages.

• Plan for negative gross-to-net financial impact, as commercial patients transition to Medicaid, based on rising unemployment.

• Work with wholesalers to increase “days on hand,” to meet demand for larger supply as patients shelter in place.

Tip: Revisit current value propositions to determine if messaging exists to address new value drivers around supply chain and revised benefit design.

Opportunity Actions
Ensure timely patient starts, adherence, and favorable outcomes • Consider “at-risk” shipment authorization of specialty products, either directly to patients or HCPs, prior to final benefit verification.


• Create opportunities for collaboration and coordination between case managers and PSP activities, including nurse-educator outreach.

• Enhance PSP offerings based on the unique needs of at-risk populations, including immunocompromised and elderly patients.

Tip: Revisit patient support and HUB services to ensure timely claims adjudication, seamless interactions with specialty pharmacies, and integration of COVID-19-related support.

Two pharma companies recently announced enhancements to their patient support programs in response to COVID-19.

  • The Lilly Insulin Value Program allows patients with or without commercial insurance to fill their monthly prescription of Lilly’s insulin product for $35.
  • Bristol-Myers Squibb has expanded its PSPs to provide access to any of its branded medicine for free, “including some of its most widely prescribed products, as well as those prescribed via telehealth services.”

We expect to see similar programs sponsored by more biopharma companies in the coming weeks.

Opportunity Actions
Drive formulary and coverage policy transparency. • Create scalable formulary/coverage look-up tools that can be updated in real time, based on expected benefit design and coverage policy changes.


• Update customer segmentation and contracting strategies to reflect changes in benefit design and utilization management controls.

Tip: Continuously monitor formulary and coverage policy changes to ensure strategic and tactical alignment, if course corrections are necessary.

Patients providers payer

Strategies aligned with the overarching brand strategies should take provider, patient, and payer influences and needs into consideration.

Relationships are typically forged during times of crisis and need. Market access marketers and account managers have a unique opportunity to assist their payer and health-system customers with timely and relevant resources that extend the effectiveness of their new initiatives and capabilities while driving collaboration with internal cross-functional colleagues and working to achieve the Triple Aim for patients. We must adapt to a new world that is grounded in technology and the use of non-personal communications. As we collectively embrace new platforms and ways of working, marketers and account managers can also proactively address forthcoming affordability and access issues that are likely to impact the large segment of the U.S. population who will continue to be financially stressed due to an uncertain recovery trajectory. In doing so, biopharma can move beyond transactional relationships to become a more valued and trusted partner for its health plan and hospital system customers, along with all other healthcare stakeholders.