Structural Forces Reshaping Managed Care Pharmacy: Where Klick Market Access Is Focused Now

What you’ll learn:

Managed care pharmacy is not simply evolving but structurally rebuilding. A $923 billion market growing at 12.5% is being reshaped by pricing policies that did not exist three years ago, evidence standards are still being written, and access models are straining under the simultaneous pressure of innovation and regulation. 

The window for pharma companies to influence these conditions is open now. By the time most launch plans are finalized, several of the forces described here will already be locked in.

GLP-1s are redrawing formulary economics. AI is moving into payer workflows faster than governance is maturing. Payer standards for evidence are becoming clearer and harder to ignore. What makes this moment different from prior cycles of disruption is the simultaneity. These forces are not arriving sequentially, giving companies time to adapt, they are arriving together, compressing the time available to respond.

A number of structural forces define this moment. Each one requires more than observation but tangible strategic action.

1. The Market Is Growing But Growth Is Becoming More Concentrated

Specialty drugs now account for 52.6% of total non-discounted spend, the first time they have represented the majority of the market. Traditional drugs grew 9.6%, versus 15.2% for specialty, and Mounjaro and Zepbound alone drove more than two-thirds of retail dollar growth in 2025. At the same time, new launches contributed just 7% of total market growth, down from 11% the year prior.

Early access is now more critical than ever. As growth consolidates and the launch window narrows, brands have less time and less room for error. Those that fail to secure and sustain managed care access at launch are far less likely to recover momentum later. There is no longer a meaningful grace period.

How Klick Market Access Helps

Klick Market Access helps brands identify the stakeholders shaping formulary decisions and build access strategies before launch, not at launch.

2. Drug Pricing Is Being Fundamentally Restructured

Maximum Fair Price (MFP) is already in motion under the Inflation Reduction Act, beginning with 10 Medicare drugs in 2026 and expanding annually thereafter. Most Favored Nation (MFN) pricing represents the next major pressure point, with projected losses of $50 billion in annual rebate revenue and 1.7 million jobs at risk over the next decade. The effects are extending beyond the US, as pharma companies make tougher portfolio and pricing decisions in response to mounting global pricing pressure.

At the same time, pressure is building across the rest of the access environment, underscoring continued momentum behind value-based arrangements. PBM reform, Medicare drug price negotiation, and ongoing debates over GLP-1 coverage are adding further strain. Taken together, these forces are pressuring access models from multiple directions.

The implication is clear: legacy pricing and contracting models are losing viability. The rebate-driven system is beginning to break down, yet many are still operating as though it will hold. The new imperative is differentiation that withstands net price compression through clinical advantage, total cost-of-care impact, and international price resilience. Pharma companies that have not yet stress-tested their access model against MFP and MFN scenarios are already behind.

How Klick Market Access Helps

Klick Market Access helps clients translate MFP and MFN scenarios into concrete coverage, access, and volume forecasts. Where value-based access is viable, we define the evidence and risk-sharing story that will resonate with payers. Our Value Chain PR practice shapes the narrative before it is shaped for you.

3. The Legislative Environment Is Fragmenting Access

The legislative environment is making access more fragmented and more local. House Reform 1 triggers a 15-month cascade of Medicaid and Medicare eligibility changes running from October 2026 through January 2027. At the same time, state-level PBM regulation continues to expand, with 311 measures now cataloged, including rebate pass-through requirements in 20 states and spread pricing prohibitions in 22.

For pharma companies, the implication is significant: a single national access strategy is no longer sufficient. As state policy diverges and Medicaid redeterminations begin, the variables shaping net price, formulary placement, and pull-through will increasingly differ by geography. Brands that rely on one national model risk missing the realities that determine access market by market.

How Klick Market Access Helps

Klick Market Access provides continuous state-level intelligence through payer research, regional segmentation, and omnichannel access strategies built for how coverage conditions vary across markets.

4. AI in Managed Care Is Advancing Faster Than the Guardrails

AI is no longer a novelty in managed care as it moves into core decision workflows. Payers are evaluating where it creates value, where it introduces risk, and how governance should evolve. Only 29% of MCOs used AI for access decisions in 2025, but payers are already moving it into formulary deliberations, budget-impact analysis, and coverage-scenario modeling.

AI-enabled workflows may process evidence differently than human P&T access decision-makers. Evidence packages built for human reviewers may not perform the same way when interpreted by AI-assisted workflows. Pharma teams that adapt their evidence and communication models first may gain a structural advantage. This is not a problem for the future but a current one.

How Klick Market Access Helps

Klick Market Access helps clients structure evidence for AI-assisted review and build market access communications designed for how payer decisions are increasingly made, not how they were made five years ago.

5. The Biosimilar Void Is a Strategic Choice, Not an Inevitability

118 biologics lose exclusivity by 2034, yet only 12 currently have biosimilars in development, leaving roughly $232 billion potentially exposed to limited competition. Even where biosimilars do enter, access barriers remain structural rather than category-specific. In IBD, discounts of 19% to 57% relative to reference products are being offset by prior authorization friction, formulary misalignment, and provider and patient hesitancy to switch.

A related implementation gap is also emerging in precision medicine. In oncology and biomarker-driven care, the challenge is no longer reimbursement, it is ecosystem orchestration: aligning biomarker education, testing pull-through, access to evidence, field enablement, and stakeholder messaging across the treatment pathway. In both reimbursement and orchestration, the issues are the same. Scientific progress alone does not guarantee access.

The strategic implication is clear. Pharma companies need to build a managed care strategy before the pressure arrives, not after. Absent biosimilar pipeline depth means competition may arrive late and all at once, while implementation gaps in specialty and precision medicine can stall adoption even when therapies are clinically relevant. Organizations building access infrastructure now will be harder to displace when competitive pressure intensifies.

How Klick Market Access Helps

Klick Market Access supports innovator brands and biosimilar entrants through claims-driven pull-through strategy, payer engagement, and access planning focused on high-opportunity geographies. For precision medicine and specialty therapies, we connect biomarker education, testing pull-through, and evidence strategy so that clinical innovation does not stall at the point of implementation.

6. Payers Have a New RWE Standard. Most Pharma Evidence Does Not Meet It.

80% of payers say they want to use real-world evidence (RWE) in formulary decisions, yet only 18% do so regularly. Payer-focused standards now exist to make RWE more usable for coverage, formulary, and reimbursement decisions across the product life cycle.

The challenge is not interest but translation. The misalignment between pharmacy and medical benefit adjudication creates friction that many RWE programs never address. Too many organizations still build access narratives around the pharmacy budget alone, even as payer organizations increasingly evaluate value through cross-benefit economics, site-of-care dynamics, total cost-of-care, patient journey friction, and downstream utilization.

Most pharmaceutical RWE programs still generate evidence payers cannot readily operationalize. The advantage now lies in building evidence that is not only rigorous, but decision-ready. The distinction between evidence that exists and evidence that changes formulary decisions is where access outcomes are increasingly won or lost.

How Klick Market Access Helps

Klick Market Access helps clients move from evidence generation to evidence activation through payer value propositions and dossiers built around how payers actually evaluate evidence, and access decision models that translate RWE into cost-per-outcome conversations. A dossier PDF is a starting point, not an endpoint.

7. Patient-Centered Care and Health Equity Are the Accountability Layer

Every structural shift described has a patient-access consequence that is not evenly distributed. Medicaid redeterminations under H.R.1 will disproportionately affect low-income, immigrant, and minority populations. Mandatory biosimilar switching can destabilize patients stabilized on existing therapies. GLP-1 formulary restrictions continue to limit access by income and insurance type. AI-assisted coverage decisions trained on historically biased claims data risk scaling existing disparities into automated workflows.

Health equity is not a standalone initiative: it is an exposure. Every structural force described in this document carries a disparate impact risk that, if unaddressed, becomes a regulatory, legal, or reputational liability. Brands that do not build equity considerations into their access strategies are both leaving patients behind and exposing themselves.

Formulary designs that generate visible access disparities are drawing scrutiny from employers, regulators, policymakers, and increasingly the media. The question is not whether equity will be evaluated,it is whether brand teams will be prepared when it is.

How Klick Market Access Helps

Klick Market Access helps clients identify and address equity exposures before they become an access or reputational challenge, through patient support programs, Medicaid-focused reimbursement pathways, and communications that make patient experience visible in formulary conversations.

From Structural Pressure to Strategic Advantage

The managed care environment is changing how therapies are priced, accessed, evaluated, and sustained. Together, these forces describe how it is evolving faster than many organizations are prepared to navigate.

The manufacturers best positioned to navigate this environment share one characteristic: they are acting on these forces now, before they are fully locked in. Access conditions established early in the product life cycle are difficult for competitors to undo. Evidence narratives built before payer expectations solidify are easier to defend. Pricing strategies stress-tested against MFP and MFN before launch are more durable than those retrofitted after the fact. 

The window to influence these conditions is open, but narrowing.

That is the work Klick Market Access is built for: helping clients act earlier, plan more precisely, and build access foundations resilient enough to withstand ongoing market pressure.

References

All references follow AMA citation style. Sources are AMCP 2026 Annual Meeting presentations and supporting literature cited within those sessions.

Klick Health is the world’s largest independent commercialization partner for life sciences and a leading full-service pharma marketing partner, serving as agency of record for leading pharma, biotech, and healthcare brands. Klick’s specialized offerings are rooted in deep medical and scientific understanding, including market insights, award-winning creative, and proprietary AI and data models to craft impactful brand narratives and seamless customer journeys. Backed by nearly 250 medical experts and advanced healthcare analytics, Klick delivers integrated marketing strategy and communications, from new product launch strategy to MLR review with real-world evidence, helping brands thrive in today’s complex healthcare landscape. Learn more at Klick.com.