Why having health coverage isn't enough

A 2025 report from Morgan Health revealed that even among workers with employer-sponsored health coverage:

◆ 14% skipped or delayed a prescription due to cost.

◆ 11% delayed care for financial reasons.

◆ 9% avoided necessary care entirely.

These statistics don't reflect a lack of benefits. They reveal a fundamental disconnect between coverage and accessibility.

The cost of a missed prescription

High drug prices are just one part of the problem.

For many employees, the real barrier isn't solely affordability; it's fear of the unknown.

Employees often don't know what their prescription will cost until they reach the counter.

The 2025 State of Drug Access report found that 42% of Americans were prescribed a medication they couldn't afford in the past year. They may not realize lower-cost options are available or that their plan offers savings programs they could use. Confusion around coverage, copays, and alternatives leads to stalled decisions, abandoned scripts, and untreated conditions.

This is especially true for lower-wage workers, many of whom are on high-deductible health plans or earn under $50,000 a year. These employees are more likely to hesitate, delay, or walk away entirely when faced with even a modest out-of-pocket charge. Since this drop-off rarely triggers an alert in traditional benefit systems, the employer may not see the risk until it becomes a larger medical claim.

To put this into perspective, consider a scenario where an asthma patient skips their maintenance inhaler. It doesn't appear in a dashboard, but a trip to the ER for respiratory distress will. What could have been a $30 prescription becomes a multi-thousand-dollar event, with avoidable consequences for employee health and plan costs.

Related: When Medicaid cuts push rural health care past the breaking point

Affordability is not just about dollars. It's about clarity, predictability, and follow-through. Without those, adherence and the employer's investment in care break down.

Why employers can't wait for claims to tell the story

Relying on retrospective claims data to identify risk is like trying to steer a car using only the rearview mirror. By the time a serious health event shows up in a report, the opportunity to intervene affordably has passed.

Instead, employers need to adopt a forward-facing approach that identifies access barriers in real time, starting at the point of prescription. That begins with recognizing a simple but critical truth: Cost is a clinical barrier, and addressing it requires clinical coordination.

The prescriber is the gateway to adherence

One of the most common missteps in benefit design is assuming that coverage guarantees access. From the employer's perspective, the benefit exists. However, access often feels like an obstacle course for the employee, especially one navigating cost concerns and a confusing array of digital tools.

When a medication is unaffordable, most patients don't open an app or call their insurance; they reach out to their doctor. Prescribers remain the most trusted source of guidance, but they may lack insight into what the patient will pay or which lower-cost alternatives are covered.

This is where smarter, clinically integrated solutions can make a measurable impact. Rather than asking prescribers to use another portal or app, some platforms now deliver affordability insights directly within the prescribing workflow. There is no disruption, no extra clicks, just relevant, real-time information that allows physicians to act quickly and appropriately.

By embedding cost transparency at the point of care, employers can build a stronger bridge between plan design and patient behavior. It turns prescriptions into an opportunity for early intervention, enabling better adherence and giving employers the visibility they need to support healthier outcomes.

Data-driven does not have to mean difficult

Traditional affordability tools often ask employees or benefits teams to do the work: navigating discount apps, comparing pharmacy prices, or searching for coupons. But the most effective solutions today are diligently working in the background.

Using client data such as drug pricing, coverage status, and claims history, modern platforms can identify affordability barriers for patients. When a problem is detected, the system automatically surfaces clinically appropriate, lower-cost alternatives to the prescriber. There is no need to open a separate system or change workflows.

Once a switch is approved, the patient is notified about the change and the savings, closing the loop and improving the chance they will follow through. This model has been particularly helpful in increasing the use of biosimilars and generics, which often go underused due to lack of awareness or prescribing friction.

These tools are designed to simplify, not complicate - helping prescribers, patients, and benefits teams take meaningful action with ease.

Benefits equity is not just the right thing, it's smart business

Ensuring every employee can access prescribed medications, regardless of income, isn't just the right thing to do; it's a financial imperative. Lower-income workers face higher rates of chronic illness and they are more likely to forgo care due to cost. When left unaddressed, this pattern leads to higher turnover, more absenteeism, and greater volatility in claims.

On the other hand, improving medication affordability and adherence supports workforce retention, enhances satisfaction with benefits, and reduces long-term spend. According to WTW, 74% of employers now view health equity as a top priority, and pharmacy access is one of the most actionable levers in that strategy.

Consider a diabetic employee who can't afford their prescribed insulin. Without intervention, that person may miss work, end up in the ER, or exit the workforce entirely. But with a timely switch to a covered biosimilar, that employee can continue treatment, stay productive, and avoid a financially devastating outcome.

Closing the affordability gap starts now

Employers don't need to overhaul their pharmacy benefits to make a difference. They simply need to close the final mile of access, where prescriptions are written but cost prevents adherence.

Smarter, data-driven interventions that identify and resolve affordability barriers in real time can dramatically reduce unnecessary cost escalation. By delivering these interventions through the prescriber, the person patients already trust, employers can improve adherence, lower spending, and create a more equitable experience for every employee, regardless of income.

Coverage is just the beginning. Access is the outcome that matters, and employers have the power to deliver it today.

Ryan Czado, PharmD, MBA, serves as chief pharmacy officer at RazorMetrics. He previously oversaw pharmacy practice growth for Lockton, and he also has worked for Express Scripts, Deloitte and Minuteman Health.