Drawing on RIS Rx’s proprietary data and case studies, Stephen highlights patterns that can undermine patient support program effectiveness. He argues that a more data-driven approach can help manufacturers identify hidden risks, improve program performance, and ensure that affordability resources reach the patients they are intended to support.
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Read on for Stephen’s insights.
Pharmacy Copay Misuse: The Multi-Billion Dollar Issue Hiding In Plain Sight
By Stephen Hom, Co-Founder, EVP & Chief Operating Officer, RIS Rx
The challenge isn’t that copay misuse exists. It’s that much of it happens quietly inside complex pharmacy workflows, making the scale of exposure larger than many realize.
Billions In Copay Spend: Hidden, Vulnerable, but Protectable
At RIS Rx, we estimate pharmacy and payer leakage copay misuse represents billions in annual leakage risk across the industry, with roughly one in ten pharmacies engaging in some form of copay misprocessing behavior.
That estimate is modeled from multiple inputs. First, ~61,000 active community and retail pharmacy NPIs across the U.S. pharmacy system (NCPDP, January 2024). Second, a blended ~9% misuse rate across all pharmacy types—derived from RIS Rx audit data and consistent with documented patterns. Third, ~$530K in average annual misuse per pharmacy, a figure RIS Rx models from its own audit data, anchored by documented fraud cases and case studies. Fourth, up to 10x ratio of undetected-to-detected misuse, referenced across consultancy analyses of healthcare fraud. We'll let the math speak for itself, but in our experience, the exposure is always larger than manufacturers expect.
Most pharmacies are trying to do the right thing in an increasingly difficult reimbursement environment: pressure from PBMs, ongoing margin compression, delayed reimbursement timing, DIR-related disruption, and broader cash flow instability.
But at the same time, copay programs represent something unusual inside healthcare: money sitting inside a largely unregulated operational space. That combination creates vulnerability. And because manufacturers rarely see what happens between the primary claim and the copay processor, much of that vulnerability stays hidden.
Uncovering the Visibility Gap
A fact that surprises almost every manufacturer we speak with: every field transmitted through the pharmacy billing process can be manipulated at the pharmacy terminal. Data fields can be adjusted, coverage classifications can be altered, and reimbursement details can change. That gap creates enormous exposure.
Manufacturers often catch the most egregious examples: a suspicious new pharmacy, an unusually high claim volume, or a pattern that looks wrong. What they usually don’t see are the thousands of smaller manipulations that compound over time.
These manipulations are why automated visibility isn’t enough.
Why Automated Detection Alone Falls Short
Many newer approaches in the market focus heavily on automated flagging or pre-payment detection. While that technology absolutely matters, pharmacy copay misuse isn’t simply an algorithm problem. It’s an operational problem happening inside a highly human system.
Because they lack the overlay of deep pharmacy expertise, many interventions stop at the point of detection. A pharmacy provides an explanation. Someone accepts the explanation at face value. The behavior continues.
That’s where pharmacist interpretation becomes critical.
How PharmD Expertise Translates to More Effective Intervention—and Greater GTN Savings
RIS Rx’s pharmacy copay misuse solution—Affordability, Audit & Assurance (Triple A)—was built and continues to operate under PharmD expertise. Our team has more than 20 PharmDs on board, including our leadership. We have seen hundreds of thousands of claims billed through various pharmacy systems.
Effective intervention requires understanding how claims are adjudicated in practice, how reimbursement pressures influence behavior, and how manipulation patterns appear within real pharmacy operations.
That changes the quality of intervention dramatically. When another PharmD calls a pharmacy and says, “We noticed this pattern,” the conversation is fundamentally different. It isn’t confrontational or accusatory, but it does change behavior.
The results bear that out. One brand saw covered benefit spend drop 48% after Triple A went live—despite a WAC increase—tripling cost avoidance from $9M to $27M year-over-year. Another brand saved $21M across 43,000 monthly transactions in only two months post go-live.
The real strength of this model comes from combining multiple capabilities simultaneously:
- Full end-to-end visibility across both primary and secondary claims
- Proprietary pharmacy intelligence developed across dozens of therapeutic areas
- Real-time intervention before claims are paid
- Pharmacist-led outreach and behavioral correction
- Pattern recognition developed through years of pharmacy auditing
Seeing the Whole System
Institutional pharmacy intelligence compounds over time, creating an extensive understanding of pharmacy behavior patterns, reimbursement anomalies, and recurring misuse trends.
In many cases, when a new manufacturer begins working with RIS Rx, we already recognize the pharmacies creating the majority of exposure because we have seen those same patterns elsewhere.
That network effect matters. It allows us to identify issues faster, intervene earlier, and drive operational change far more quickly than fragmented review processes.
Get Your Custom, Complimentary Analysis
Preserving the integrity of affordability programs is more than just a financial responsibility. It’s a clinical one.
See how leading manufacturers are strengthening affordability oversight with Triple A. Request your complimentary analysis.
About RIS Rx
RIS Rx is a healthcare technology company delivering gross-to-net (GTN) revenue protection for the world’s leading pharmaceutical manufacturers. Through proprietary software, real-time analytics and pharmacist-led expertise, RIS Rx helps clients optimize operations, eliminate leakage and ensure that financial assistance reaches the patients who need it most. In 2025 alone, the company protected more than $1 billion in revenue for its customers. Founded by pharmacists and headquartered in Irvine, California, RIS Rx serves leading pharmaceutical manufacturers across a growing portfolio of drug brands.
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