Integrated health system specialty pharmacies (iHSSPs) face increasing challenges to secure patient access to high-cost specialty medications in today’s health care landscape. New third-party benefit models such as alternative funding programs (AFPs), copay accumulators, and copay maximizers are increasingly being adopted by health plan payers as cost-containment tools.1 Although these programs reduce employer and insurer costs, they can introduce significant challenges for patients and care teams. All 3 programs can present challenges to maintain consistent, clinically appropriate therapy.1
Copay maximizers and accumulators can initially lower patient out-of-pocket costs but, over time, can erase much of the savings patients would otherwise gain through manufacturer copay card programs. In some cases, patients are left responsible for high deductibles and other out-of-pocket costs.2 AFPs completely exclude specialty medications from their formularies and push patients to secure coverage through alternative funding sources.The past decade has shown accelerated growth in employer adoption of these third-party plans.3 As their prevalence increases, patients are left with increasing anxiety over the possibility of losing access to potentially life-saving specialty medications.1
Within iHSSPs, understanding the impacts of these payer models is critical. The ability to anticipate access delays, navigate benefit changes, and protect continuity of care has become a defining role of modern pharmacy practice.
Understanding the Plans
Alternative Funding Programs
AFPs are typically contracted by self-funded employer plans.2 To minimize costs, these insurance plans exclude specialty medications from their formulary and instead partner with an AFP to secure coverage through alternative routes. AFPs differ in the way they approach securing coverage, but all are designed to reduce employer costs by redirecting high-cost specialty drugs away from traditional coverage pathways, and patients are instead tasked with securing their medications through patient assistance programs, charitable foundations, or other non-traditional sources.2 Examples of AFP coverage sources include manufacturer patient assistance programs (PAPs), charitable foundations, and overseas distributors.1,2
Patients are rarely aware of their insurance plan’s partnership with an AFP until they encounter unexpected barriers while attempting to fill a specialty medication. These AFPs may offer reduced plan costs to employers but often create delays in therapy, confusion, and fragmented care coordination.1 Table 1 highlights key data on AFPs.
Copay Accumulators and Copay Maximizers
Although AFPs operate outside the traditional benefit design, copay accumulators and maximizers modify how assistance is applied within the plan itself. 1 In copay accumulators, manufacturer assistance dollars do not count toward a patient’s deductible or out-of-pocket maximum. Copay assistance funds are used up-front, and patients may be met with unexpected cost spikes when assistance runs out.1
In a hypothetical example, say Jane’s commercial insurance plan has a $7000 deductible. Her specialty drug has a copay of $1000 per month. Jane finds a manufacturer’s copay card with a yearly cap of $4000. Without a copay accumulator, her manufacturer copay card pays $1000 per month toward her copay and deductible for the first 4 months of the year. Jane then owes a total of $3000 for the rest of the year.
Now take the same scenario with a copay accumulator. Now, Jane’s manufacturer copay card would pay $1000 per month toward her copay but would not contribute toward her deductible. Jane then pays $0 for the first 4 months of treatment but owes a total of $7000 for the rest of the year.
For copay maximizers, manufacturer assistance dollars do not count toward a patient’s deductible or out-of-pocket maximum. Unlike accumulator plans, copay assistance is spread evenly throughout the benefit year.1
Although these programs manage overall plan expenses, they can create unanticipated cost exposures for patients. Patients often face abrupt therapy interruptions when manufacturer support runs out, leading to medication gaps, disease flare-ups, and added utilization of acute care services.2
Copay Program Prevalence and Patient Exposure
The scope of these programs is substantial, affecting tens of millions of commercially insured individuals.3 Understanding the scale can help health systems prioritize patient navigation and benefit verification efforts. Table 23 highlights the number of patients affected.
These data underscore that patient risk is inherent in these plan designs, particularly for those using high-cost specialty medications. Health system pharmacists and care teams must proactively verify benefits, educate patients, and coordinate manufacturer assistance to prevent therapy disruption.
Impact on the Health Systems
AFPs in particular have posed a significant barrier to medication access. Patients and providers are left confused as to why first-line treatment options, which would normally be approved after prior authorization, are denied by insurers. More confusion is introduced when patients are told that they need to apply for a PAP, a pathway traditionally reserved for low-income or uninsured patients.2 In some cases, patients are told they need to seek coverage through a charitable foundation or coordinate shipments of medication from overseas prescription distributors.
Copay maximizers, accumulators, and AFPs have introduced a disruption in an already delicate health care ecosystem. While federally funded programs like Medicare and Medicaid are not directly impacted by these plans, commercially insured patients, who pay significantly into these federal programs, are negatively impacted. As AFPs, accumulators, and maximizer plans expand, more commercially insured patients face delays, denials, and financial vulnerability.1
Regulation
Many plans implementing copay maximizers, accumulators, and AFPs have carved out specialty medications from their formulary by classifying them as non-essential health benefits, a practice that, in many cases, violates the Affordable Care Act (ACA). The ACA generally requires health insurance plans to cover essential health benefits, including prescription drugs.4 However, self-insured plans, which typically contract with AFPs, are exempt from this requirement.4 Because the ACA also mandates annual limits on patient cost-sharing (including deductibles, coinsurance, and copayments), the use of copay maximizers and accumulators directly conflicts with these protections.1
In 2023, a federal court issued a decision in the case of HIV and Hepatitis Policy Institute et al v. Health and Human Services (HHS), striking down the 2021 HHS rule that had permitted widespread use of copay accumulator programs.1 Despite this ruling, federal oversight and enforcement have remained limited, and many health plans continue to exclude manufacturer copay assistance from patients’ cost-sharing obligations.1 Additionally, there are no federal restrictions on AFPs to date.
At the state level, more than half of US states have begun passing local legislation targeting copay maximizers and accumulators.1 While these laws represent an important step toward curbing harmful cost-sharing practices, they do not apply to patients enrolled in self-funded employer or large-group plans, limiting their overall impact.1
A Call to Action
AFPs, copay maximizers, and copay accumulator plans are no longer fringe benefit designs; they are widespread policies that directly disrupt patient access, therapy continuity, and trust in the health care system.1,3 Although often positioned as cost-containment tools, these models increasingly shift financial and administrative burden onto patients, pharmacies, providers, and manufacturers.1
It is because of these challenges to pharmacies, providers, and manufacturers that it is time for the whole health care community to work together to come up with a solution to help patients secure better access to therapy without delays that can often lead to worsening conditions.
Standing together—through education, advocacy, employer engagement, and policy reform—health care stakeholders can reinforce a simple principle: coverage should enable access, not create barriers. Aligning against AFPs, maximizers, and accumulators is not about cost avoidance; it’s about protecting patients, preserving care continuity, and restoring transparency and accountability in prescription benefit design.
Integrating Technology
As technology and artificial intelligence (AI) continue to be integrated into health care and specialty pharmacy, it will become increasingly important for staff to effectively leverage these tools to proactively identify patients enrolled in market-disruptive insurance plans before issues arise.5 Under the current prescription model, patients are often not identified as having these plans until after a specialty medication has already been prescribed, frequently resulting in delays to potentially life-saving care.
AI is already being used by many manufacturers to identify patients enrolled in these disruptive plans. As more pharmacies, providers, and hospital systems begin adopting AI-driven technologies, we have the opportunity to move from a reactive approach to a proactive one. One of the areas with the greatest potential impact is early identification of patients enrolled in these plans.5 With early detection, delays and barriers in therapy can be caught before the patient is even prescribed a medication.
Conclusion
As AFPs, copay accumulators, and maximizers continue to expand, health systems must take an active role in evaluating their effects on patient experience and therapy continuity. These models may deliver financial advantages for employers in the short term, but they also require higher levels of regulation and advocacy to ensure equitable, uninterrupted care.
Health systems, specifically iHSSPs, are uniquely positioned to lead this work—combining clinical insight, data visibility, and patient-centered care models to balance affordability with access.
About the Authors
Zach Waggoner is a pharmacy professional with 18 years of experience, including 8 years specializing in medication assistance and specialty pharmacy support. As a Medication Assistance Coordinator III, he focuses on improving patient access and navigating copay assistance programs, accumulators, maximizers, and alternative funding strategies.
Sarah Patterson, PharmD, is a specialty clinical pharmacist II at Outpatient Pharmacy Services, a specialty pharmacy integrated within the Yale New Haven Health System. Her work focuses on advancing interdisciplinary collaboration to improve patient care and support patient autonomy within an increasingly complex health care landscape.
REFERENCES
Anderson MK, Newsome T. Alternative funding programs: implications for patient care. Network for Collaborative Oncology Development & Advancement. September 25, 2025. Accessed May 27, 2026. https://ncoda.org/news/alternative-funding-programs-implications-for-patient-care/
Apolito C, Castagna K. Unlocking AI’s promise in patient support programs. Drug Channels. January 31, 2025. Accessed May 27, 2026. www.drugchannels.net%2F2025%2F01%2Funlocking-ais-promise-in-patient.html
