In the competitive pharmaceutical landscape, securing a favorable spot on a payer’s formulary is only half the battle. Even when a drug is listed as preferred or tier-1 (meaning little to no co-pay for patients), physicians may not always be aware of its cost advantage for their patients.
To bridge this gap, pharma companies must align prescribing physicians and hospitals with the insurance networks and pharmacy benefit managers (PBMs) that list their drug favorably. By identifying in-network providers and tailoring targeted messaging to them, companies can significantly reduce prescription barriers and improve market access.
This article explores how pharma companies can leverage high-quality data and advanced analytics to connect in-network providers with high-formulary drugs, ensuring that cost is not a barrier to prescription.
The Connection Between Formularies, PBMs, and In-Network Providers
Every insurance plan or PBM maintains a formulary—a list of drugs they cover, ranked by preference. A tier-1 or preferred status usually means the drug is the most affordable option, sometimes with no co-pay at all. But formulary placement alone doesn’t guarantee uptake.
Doctors don’t always have visibility into which drugs are covered for which patients. They may default to prescribing what they are most familiar with, unaware that an equally effective drug may be a better financial option for the patient.
Here’s where things get even trickier: not all doctors can prescribe every preferred drug under every insurance plan. A physician’s ability to prescribe and have it reimbursed depends on whether they are in-network with the insurance company or PBM that offers the favorable formulary placement.
If a pharma company can align these two pieces—preferred formulary placement and in-network providers—it can create a seamless prescribing experience for both doctors and patients.
How Pharma Companies Can Map In-Network Doctors to Favorable Formularies
The first step is gathering data. Market access teams need to pull information from a few critical sources:
- Formulary lists from PBMs and insurers – This tells them which payers place their drug in a favorable tier.
- Provider network databases – These show which physicians and hospitals are in-network for each insurance plan.
- Claims data and prescribing trends – This provides insight into which doctors are already prescribing the drug and where opportunities exist to improve uptake.
By cross-referencing these data points, pharma companies can pinpoint which doctors see patients who are most likely to benefit from the drug’s top-tier formulary status.
For example, let’s say a diabetes drug is tier-1 for UnitedHealthcare and Cigna, meaning patients covered by these insurers can get it with little or no co-pay. If Dr. Johnson is in-network with both UnitedHealthcare and Cigna but is prescribing a competing drug that comes with a higher out-of-pocket cost, he becomes an ideal target for formulary education.
Once the connections are made, the next challenge is delivering this information to physicians in a way that makes sense and influences prescribing behavior.
The Role of Data Quality and Analytics in Market Access Success
None of this strategy works without high-quality data and effective analytics. Inaccurate, incomplete, or outdated data can lead to misaligned targeting, wasted resources, and missed opportunities.
Why Data Quality Matters
- Ensures accurate targeting – Without clean and integrated data, pharma companies may reach out to the wrong providers or fail to identify key prescribers.
- Prevents compliance risks – Poor data can lead to misrepresentation of formulary status, which can create legal and regulatory challenges.
- Improves ROI on sales and marketing efforts – Better data means more precise physician engagement, fewer wasted interactions, and higher prescription conversion rates.
How Advanced Analytics Enhances Market Access
- Predictive modeling – AI-driven analytics can forecast which providers are most likely to switch prescriptions based on payer coverage, prescribing history, and patient demographics.
- Real-time data integration – Connecting EHR systems, claims data, and payer formularies ensures that reps and digital tools deliver up-to-date and relevant messaging.
- Automated physician prioritization – Machine learning models can rank prescribers based on their likelihood to prescribe a top-formulary drug, allowing for hyper-focused sales outreach.
A pharma company using outdated or disconnected data risks making strategic missteps—failing to identify the right providers, missing coverage changes, or underutilizing their market access teams.
Making Sure Doctors Know: Effective Messaging Strategies
Doctors are bombarded with information daily. If market access teams want to make an impact, they need to deliver formulary insights in a way that is relevant, easy to understand, and actionable.
Direct Conversations with Sales Reps and Medical Science Liaisons (MSLs)
Nothing beats a direct, well-informed conversation with a sales rep or an MSL who understands a doctor’s practice. Instead of a generic pitch about the drug’s benefits, these conversations should be highly personalized:
“Dr. Johnson, 75% of your patients are covered under UnitedHealthcare or Cigna, and our diabetes medication is tier-1 on both plans. That means most of your patients can get it with a $0 co-pay. Would you consider switching some patients to a lower-cost option that works just as well?”
Integrated Messaging Within Electronic Health Records (EHRs)
Doctors often rely on EHR systems for prescribing decisions. If pharma companies can integrate real-time formulary and payer data into these platforms, physicians can see immediately whether a drug is the best financial option for their patient.
Digital Outreach and Targeted Campaigns
Beyond face-to-face conversations, pharma companies should be using email, SMS, and digital portals to keep doctors informed about formulary advantages.
Partnering with Hospitals and Integrated Delivery Networks (IDNs)
Working with P&T committees can ensure that hospital guidelines align with payer formularies, making it easier for doctors to prescribe the preferred drug.
How D2Strategy Can Help Pharma Companies Optimize Market Access Data
At D2Strategy, we specialize in helping pharma companies unlock the full potential of their data to improve market access and payer analytics.
What We Offer
- Data cleansing & integration – We ensure your physician targeting is based on the most accurate, up-to-date payer and provider data.
- Advanced analytics & AI-driven insights – Our predictive models identify high-value prescribers and optimize messaging strategies for maximum impact.
- Real-time formulary monitoring – We track payer and PBM changes to help pharma teams stay ahead of market shifts.
- EHR and CRM integration – Our solutions connect prescriber intelligence directly into sales rep workflows, ensuring real-time insights drive engagement.
With D2Strategy, pharma companies can make data-driven decisions, improve physician engagement, and ultimately, increase prescription volume for their top-formulary drugs.
Conclusion
A drug’s preferred status on a formulary is only valuable if doctors know about it and can prescribe it with ease. By mapping in-network providers to top-formulary drugs, pharma companies can connect the dots between payer coverage and physician prescribing behavior.
With high-quality data and effective analytics, market access teams can ensure that doctors have the right information at the right time, leading to better patient outcomes and improved business success.