Impact of the COVID-19 Pandemic on the Payer Landscape



The COVID-19 pandemic has challenged the healthcare community and care seekers to reimagine how we interact and how we deliver and consume care.

While regulatory checks and balances are needed to minimize waste and contain costs in the healthcare system, right now it is more important to minimize barriers to care as these can lead to unintended consequences. CMS and payers agree. As such, the Centers for Medicare & Medicaid Services (CMS) has adjusted some rules so that HCPs can focus on those who need care, and patients can access timely care with relative ease.


CMS Adjustments

  • Fast-tracking State Medicaid waivers specifically targeting changes to make needed care more accessible during the COVID-19 pandemic.
  • Encouraging payers to waive or relax refill-too-soon and utilization management (quantity limit, step-therapy, prior authorization) restrictions.
  • Social distancing and quarantine may limit how and where patients get their prescriptions. Part D plans are permitted to voluntarily relax any plan-imposed policies that may discourage certain methods of delivery, such as mail or home delivery, for retail pharmacies that choose to offer these delivery services.
  • Part D plans must suspend all quantity and days’ supply limits under 90 days for all covered Part D drugs other than such limits resulting from safety edits.
  • Reimbursement of enrollees for prescriptions obtained from
    out-of-network pharmacies.
  • Any COVID-19 vaccine and its administration will be covered
    under Medicare Part B, and therefore would be excluded from Part D coverage.
  • Traditional Medicare and Medicare Advantage Organizations have also expanded telehealth services to provide enrollees the ability to obtain services in any geographic area and from a variety of settings, including beneficiaries’ homes.

Mosaic Group, the FCB Health market access agency, reached out to payers to assess their “new normal” during the COVID-19 pandemic.

Survey responses indicate that payers are being nimble and flexible, allowing HCPs to do their best work and provide support to patients when they are most vulnerable.

How Payers are Adapting

  • Some payers are making changes to member cost share (copay/deductible reductions, copay/deductible waivers) to resolve affordability issues.
  • Three-quarters of surveyed payers are allowing 90-day supply for medications used to treat chronic conditions.
  • Similar percentage of payers are easing point-of-service restrictions like refill-too-soon and/or other utilization management features to promote uninterrupted access to needed care for chronic conditions.


While payers are shifting focus to COVID-19, they remain committed to sound formulary and coverage strategies that promote the use of safe and cost-effective medications. Payers are not able to engage with the pharmaceutical industry in person, but the interest in collaboration remains strong. Here are some insights you may want to consider when engaging payers:

  • >90% of the payer work force is working remotely.
  • Webex and Zoom work best for most of the payers we surveyed.
  • >75% of payers are still open to making non-maintenance formulary changes; however, the timeframe for committing to formulary changes may vary from one payer to the next.
    Some payers are open to changes as early as Q3-Q4 of 2020 while other payers feel more comfortable delaying changes
    until early 2021.
  • Every effort is being made to continue pharmacy & therapeutic (P&T) meetings on schedule but there may be some payers who postpone/cancel P&T meetings.

  • The impact of supply chain issues that may result in drug shortages is magnified in emergency situations that already pose access to care challenges for patients. With that in mind, payers are interested in supply chain issue details from pharma as soon as possible. This information will also be valuable to downstream distribution channels as they are ultimately dispensing medications to patients and HCPs.
  • Payers have also requested that pharma disseminate information about patient support programs directly to dispensing pharmacies and patient.


Considerations For You

  • Availability of existing and new resources in a digital format.
  • Proactive communication about supply chain issues, including drug shortages.
  • Increased unemployment may shift population from commercial to Medicaid, potentially impacting existing market shares.
  • Payers are trying to maintain business-as-usual operations
    (P&T frequency, formulary decisions).
  • Access is temporarily relaxed, however payers will eventually revert back to prior utilization management strategies.
  • Long-term consequences may include further restrictions to offset COVID-19 financial impact.


Please contact your account leads or if you have any questions or would like to discuss any of the above.