Table of Contents
- Why the beginning of the year is the most frustrating time for prescriptions
- Deductibles reset and prescription costs suddenly spike
- Formularies change and “covered” medications are no longer covered
- Prior authorizations and step therapy create delays
- Confusion around pharmacy benefits and who to call
- Specialty and high cost medications create the biggest shock at the beginning of the year
- Why these problems are common with Traditional PBMs
- How a Pharmacy Benefit Solutions approach reduces friction at the beginning of the year
- Final Thoughts: Prescription problems at the beginning of the year are predictable and preventable
- Key Takeaways
Why the beginning of the year is the most frustrating time for prescriptions
For many employees, the beginning of the year is when prescription benefits suddenly stop feeling simple.
What worked just a few weeks ago may no longer work the same way. Prescriptions that were easy to refill at the end of last year can become confusing, more expensive, or delayed in the first few months of the new year.
This happens because pharmacy benefits reset. Deductibles start over, formularies can change, and out-of-pocket costs often increase. Employees may not realize these changes are coming until they are standing at the pharmacy counter, being told their medication costs much more than expected.
Not surprisingly, this is when employers start hearing from their teams. Questions, complaints, and frustrations tend to show up quickly after the holidays as employees try to refill prescriptions or manage ongoing conditions. In many cases, HR becomes the first place employees turn for help.
The good news for employers is that these prescription problems are not random. They are common, predictable, and often preventable with the right pharmacy benefit strategy. Every year, the beginning of the year reveals how clear (or confusing) a pharmacy benefit plan really is for employees.
Employer awareness around this issue is growing. According to the 2025 U.S. Workforce Trends Benchmarking Survey, 21% of employers review pharmacy contracts specifically to control rising prescription drug costs, and nearly one in three plan to expand benefits to simplify the employee experience.¹
This signals a broader shift in how employers are thinking about pharmacy benefits. Rather than accepting confusion as unavoidable, more employers are questioning traditional PBM models and looking for more supportive pharmacy benefit solutions that focus on clarity, cost control, and employee support especially during the first few months of the year, when problems are most likely to surface.
Deductibles reset and prescription costs suddenly spike
At the beginning of the year, one change causes more prescription frustration than almost anything else: deductibles reset.
In December, many employees know exactly what they will pay at the pharmacy. Their deductible has been met, their copay is familiar, and refilling a prescription feels routine. When the new plan year starts, that same prescription can suddenly cost much more (sometimes even the full price) until the deductible is met again.
For employees, this usually shows up as a surprise at the pharmacy counter. There is little warning, limited explanation, and no time to prepare. It’s easy to understand why frustration builds quickly, and why those concerns often end up with HR or the employer.
When prescription costs increase unexpectedly, some employees make tough choices. They may delay filling a medication, skip a refill, or leave the pharmacy without it. A recent research shows that higher out of pocket costs are closely linked to prescription abandonment, especially when the price increase comes as a surprise early in the year.²
For employers, this leads to more questions, more complaints, and more time spent helping employees navigate pharmacy issues. It can also affect employee health and productivity when medications are delayed or skipped.
The key takeaway is simple: these cost spikes are common at the beginning of the year, and they follow a predictable pattern. Understanding how deductible resets impact prescriptions is the first step toward reducing frustration for employees in the first few months of the year.
Formularies change and “covered” medications are no longer covered
Another common issue employees face at the beginning of the year is a change in the drug formulary.
A formulary is simply the list of medications a pharmacy plan covers and how those medications are priced. When a new plan year starts, that list can change. A medication an employee took all last year may suddenly be treated very differently.
In the first few months of the year, employees may discover that a medication is now:
- No longer covered
- Moved to a higher cost tier
- Subject to new rules like prior authorization
The biggest challenge is that employees are rarely informed about these changes ahead of time. Most only find out when they try to refill a prescription and are told the cost has increased or the medication needs approval.
For employees, this creates confusion and frustration. For employers, it can lead to distrust in the benefits plan. Employees may feel like something was taken away or changed without explanation, even though formulary updates are common in traditional PBM models.
In many cases, employees are then forced to switch medications quickly or work with their doctor to find an alternative. This can be stressful, time consuming, and disruptive especially for those managing chronic conditions.
These situations highlight a key difference in how pharmacy benefits are managed. Traditional PBMs often prioritize rebate structures, which can lead to frequent formulary changes. Pharmacy Benefit Solutions, on the other hand, place more emphasis on continuity of care and cost clarity, helping reduce unexpected disruptions for employees at the beginning of the year.
Confusion around pharmacy benefits and who to call
For many employees, pharmacy benefits are one of the most confusing parts of their health plan. This confusion becomes especially clear at the beginning of the year, when questions and issues start piling up.
Employees often do not fully understand how their pharmacy benefits work. They may be unsure what medications are covered, how much they are expected to pay, or how pharmacy benefits differ from medical coverage. When something goes wrong at the pharmacy, many employees are not sure who can actually help resolve the issue.
As a result, HR often becomes the default support desk. Employees reach out with questions about copays, deductibles, prior authorizations, and denied prescriptions, even though these issues are managed outside of HR. This creates time-consuming, manual work for employer teams.
Research shows this confusion is widespread. According to a MetLife survey of more than 2,600 U.S. workers, nearly 45% of employees say there are elements of their benefits package they do not fully understand, even after going through open enrollment.³ Pharmacy benefits are frequently one of the most misunderstood areas.
For employers, this lack of clarity leads to frustration on both sides. Employees feel unsupported, and HR teams spend valuable time trying to track down answers. At the beginning of the year, when benefit changes are already top of mind, this confusion becomes even more noticeable.
Clear communication and better pharmacy support can significantly reduce these issues. When employees know what to expect and who to contact for help, problems are resolved faster and frustration is reduced.
Specialty and high cost medications create the biggest shock at the beginning of the year
For employees who rely on specialty or high cost medications, the beginning of the year can be especially difficult.
Medications used to treat chronic conditions, complex illnesses, or newer therapies, including many specialty drugs and GLP 1 medications, often come with much higher price tags. When the plan year resets, employees may move from paying a manageable copay to facing coinsurance or full deductible costs instead.
This change can feel sudden and alarming. A prescription that felt affordable at the end of last year may now cost hundreds or even thousands of dollars in the first few months of the year. For many employees, this creates stress, confusion, and real concern about whether they can continue their treatment.
From the employer perspective, these medications often drive a significant portion of pharmacy spend early in the year. At the same time, employees taking these medications may feel that their benefits are no longer meeting their needs, leading to dissatisfaction with the overall health plan.
These situations highlight one of the biggest challenges with traditional pharmacy benefit structures. High cost medications tend to expose gaps in plan design, communication, and support especially when employees are left to navigate complex pricing and approval requirements on their own.
At the beginning of the year, when costs reset and questions increase, specialty medication issues can quickly become one of the most visible and impactful pharmacy benefit problems employers face.
Why these problems are common with traditional PBMs
When employers look at all of these issues together (rising costs, confusion, delays, and employee frustration) a common question comes up: Why does this happen every year?
The answer often lies in how traditional PBMs are designed to operate.
Traditional PBMs tend to focus heavily on rebate driven strategies, complex pricing structures, and frequent formulary changes. While these approaches may benefit the system behind the scenes, they can make the employee experience more complicated, especially at the beginning of the year when benefits reset.
Because formularies are frequently adjusted and approvals are tied to changing rules, employees are more likely to encounter surprises. Medications may move to different tiers, require new authorizations, or cost more without clear explanation. Support for employees is often limited, leaving them to navigate these challenges on their own or turn to HR for help.
The first few months of the year tend to expose these weaknesses more clearly than any other time. Deductibles reset, new rules apply, and employees who were previously stable suddenly face barriers to access or affordability. What feels like a series of unrelated problems is often the result of a system that was not designed with clarity and employee experience as a priority.
This is why many employers are beginning to question whether traditional PBM models are the best fit for their workforce. As pharmacy costs rise and employees expect more transparency and support, these recurring issues have become harder to ignore.
Understanding this connection helps employers see that beginning of the year prescription problems are often built into how pharmacy benefits are managed.
How a Pharmacy Benefit Solutions approach reduces friction at the beginning of the year
Many of the prescription problems employees face in the first few months of the year are not unavoidable. They are often the result of how pharmacy benefits are structured and supported.
A Pharmacy Benefit Solutions approach looks at pharmacy benefits differently. Instead of reacting to problems after employees complain, the focus is on reducing confusion and friction before issues arise.
Rx Optimization Programs play an important role in this approach. These programs are designed to help employees access their medications at lower out-of-pocket costs, avoid unnecessary disruptions, and get support when questions come up. This can include guidance around formulary options, help navigating approvals, and advocacy when pricing or access becomes a challenge.
Transparency is another key difference. When employees have a clearer understanding of what their medications will cost and what to expect at the pharmacy, there are fewer surprises at the beginning of the year. Proactive communication and ongoing support help employees feel more confident using their benefits.
For employers, the impact is meaningful. Fewer unexpected issues at the pharmacy lead to fewer complaints and fewer last-minute questions for HR teams. Employees feel more supported, and pharmacy spend becomes easier to anticipate and manage during the first few months of the year.
Rather than accepting confusion as part of the annual benefits cycle, employers who take a Pharmacy Benefit Solutions approach are better positioned to create a smoother experience for employees when it matters most.
Final Thoughts: Prescription problems at the beginning of the year are predictable and preventable
For many employers, prescription issues in the first few months of the year can feel overwhelming and out of their control. Complaints increase, questions pile up, and employees become frustrated with costs and access to medications.
The reality is that these challenges are not a reflection of poor plan management or employee behavior. They are common, predictable outcomes of how pharmacy benefits are traditionally structured, especially when deductibles reset and plan rules change.
With the right PBM partner and a more supportive Pharmacy Benefit Solutions approach, many of these issues can be reduced or avoided altogether. When pharmacy benefits are designed with clarity, transparency, and employee support in mind, the beginning of the year does not have to be the most difficult time for prescriptions.
For employers, this is an opportunity to rethink pharmacy benefits not just as a cost line item, but as a strategic part of the employee experience. A smoother pharmacy experience leads to healthier employees, less frustration, and fewer disruptions for HR teams during the busiest benefits season of the year.
Key Takeaways
- Prescription problems tend to spike in the first few months of the year when deductibles reset and plan rules change
- Unexpected pharmacy costs are one of the biggest drivers of employee frustration and prescription abandonment
- Formularies, prior authorizations, and specialty drug pricing often create confusion without clear communication
- Employees frequently turn to HR for help because pharmacy benefits are hard to understand
- Traditional PBM models can make these issues more common through complexity and limited support
- A Pharmacy Benefit Solutions approach with Rx Optimization can reduce confusion, lower out-of-pocket costs, and improve the employee experience
