Coverage resets and benefits reverification season: What every practice should know

The beginning of each year looks the same across care teams: every January brings not only a new calendar year, but also an influx of administrative work ushered in by annual benefit resets, renewed prior authorizations, formulary shifts and coverage reverification requirements.

What makes this year different is not that benefits are changing, but that the scale and complexity of those changes now routinely exceed what practices were designed to handle.

Although we know this surge will come, it can still be disruptive, forcing care teams to juggle everything from routine scheduling to medication initiation. Another factor exacerbating an already busy time is the growing scale of this annual process: therapies are becoming more complex, patient expectations are higher, and benefit designs are changing in ways that are increasingly difficult for practices to keep pace with, even compared to what care teams faced just a few years ago.

This flurry of activity ultimately impacts the patient: 65% of patients report delays in accessing needed medications, and more than half say they’re concerned about rising drug costs. For clinicians, those same forces translate into an administrative load layered onto a workforce that is already lacking bandwidth. So, although the season recurs each year, the operational work has continued to intensify over time.

Market forces making an impact

This year, benefits reverification season is colliding with a wave of more complex therapies across core primary care, and it’s just not limited to GLP-1s. We know atypical antipsychotics, non-hormonal menopausal treatments, cardiometabolic drugs, respiratory biologics and migraine therapies all have experienced tight coverage controls. This may look like:

• Shorter prior authorization windows, expanded documentation requirements and more frequent benefit checks. In fact, 81% of patient access professionals report documentation required to complete prior authorization submissions has increased in recent years, highlighting the growing administrative work placed on care teams involved in medication access.
• Additional chart reviews before visits, more follow-up after denials and extra coordination with pharmacies to prevent therapy delays and maintain continuity of care.
• Employer-sponsored plans tightening utilization to manage rising drug costs and a rise in telehealth-initiated prescriptions, which ultimately route back to care teams.

Providers and their staff can have a hard time accommodating these changes as administrative capacity hasn’t kept pace. Staffing shortages and fragmented systems have made it harder to manage day-to-day operations, let alone the spike in benefit-related work early in the year. This cognitive overhead—constant task-switching between clinical decision-making, payer rules, and coverage troubleshooting—forces clinicians to toggle between clinical care and administrative work, often at the detriment of the patient experience.

Additionally, we see patients entering the season with higher expectations. They expect clear answers on costs and coverage at the point of care, and when plans change, the frustration is usually directed at the practice. So, we don’t see benefits reverification season as just a bureaucratic cycle; it represents a convergence of rising therapeutic complexity, limited administrative bandwidth and a patient experience shaped by changing expectations.

Why is this still hard?

Even with all the new pressures, the core challenges of benefits reverification season look familiar, just amplified.

1. 86% of providers report traditional prior authorization submissions, which rely heavily on phone calls, faxes, and portal hopping, interfere with patient care.
2. Many practices face confusion around whether a therapy is covered under pharmacy or medical benefit, which can derail requests before they even start.
3. Communications supporting this work haven’t improved much, either, with practices still relying heavily on manual, fragmented exchanges despite widespread digitization elsewhere in care delivery.
   1. Practices still navigate looping exchanges between pharmacies, health plans and pharmacy benefit managers (PBMs), and care teams to clarify coverage, update documentation or chase down missing details.
   2. EHR formulary data often lags behind patient-facing plan changes, so staff may not realize a medication has moved tiers or gained a new authorization requirement until the denial arrives.
   3. Care teams manage tasks on upwards of nine different digital applications, contributing to inefficiencies and, ultimately, burnout.

Individually, none of these issues are new, but together, they compound into a level of friction that is increasingly incompatible with modern primary care workflows.

As a result, early each year we see a similar pattern: an initial surge of denials, therapy restarts, reauthorizations and slow-moving appeals that drag well into the spring. The volume shifts, the therapies change, but the bottlenecks persist.

How do you navigate what’s coming?

• One of the best things a provider can do as they look ahead is to strengthen collaboration with local pharmacies. Pharmacists are often the first to see benefit changes and can flag impending issues before a prescription stalls. Establishing a simple feedback loop, whether through shared messaging channels, routine check-ins, or agreed-upon points of contact, helps practices anticipate requirements and pivot to preferred alternatives before a denial triggers a cascade of extra work. When pharmacies and practices coordinate proactively, the time saved shows up immediately in fewer callbacks and smoother restarts.
• Electronic prior authorization (ePA) solutions, where available, can also streamline a process that has long depended on phone and fax. While it doesn’t eliminate coverage requirements, ePA helps make them fast and clear and often results in faster determinations than phone or fax methods. As more states adopt ePA mandates, PBMs standardize data exchange, and EHRs integrate ePA workflows, electronic submission is becoming the default. What this means for practices is:
• Cutting down on back-and-forth by surfacing missing clinical details early,
• Providing real-time status updates, and
• Reducing the number of requests that stall for lack of information.
• Setting expectations with patients earlier in the cycle can help prevent confusion and frustration once January arrives. Coverage variability is the one thing we can predict year over year, so discussing deductibles, drug costs and potential plan changes in the fall gives patients a clearer sense of what to expect. This is especially important for therapies that routinely require reauthorization. When patients understand the timing and the mechanics, practices face fewer urgent messages or disruptions during visits. While this approach won’t reduce the administrative load entirely, it makes the season more manageable.

While none of these steps eliminate benefit complexity, they can meaningfully reduce rework, interruptions, and avoidable delays that characterize the start of the year and this season.

What do we see ahead of us?

Benefits reverification season is a dynamic time not only because of changing plans, but the nature of treatment itself is shifting. Primary care is increasingly managing higher cost and more specialized therapies, many of which carry demand more frequent and complex prior authorization requirements that expand documentation expectations for care teams^.

We hear all the time that many practices feel like the current infrastructure wasn’t built for the reality they’re operating in. Each time the calendar turns, a gap is clearly exposed. Benefits reverification season has become a barometer for how much care delivery has changed. The question we must solve for is: how can practices build the capacity to manage that complexity without sacrificing time, attention and momentum in clinical care?

Looking ahead, addressing this gap will require more incremental fixes. Practices increasingly need centralized, EHR-integrated workflows that reduce fragmentation and automate routine administrative tasks. As benefit navigation and prior authorization continue to grow in complexity, automation and AI-enabled decision support will be critical to helping care teams manage volume while preserving clinical time for direct patient care.

Matt Hare is Vice President of Client Success & Network Growth at CoverMyMeds. He has dedicated the past decade to advancing access through a variety of roles, helping patients get the medicine they need to live healthier lives. In his current position at CoverMyMeds, he focuses on building and maximizing partnerships with health systems, EHRs, pharmacy chains, and system vendor partners to improve medication access and streamline workflows.