Co-Pay Models and AFPs Shift Costs but Raise Access Concerns: Patty Taddei-Allen, PharmD, MBA

Co-pay accumulators, maximizers, and alternative funding programs (AFPs) are rapidly growing cost-containment strategies used by insurers and pharmacy benefit managers (PBMs) to manage rising prescription drug spending. However, while they are often grouped together, each model functions differently in how costs are distributed between patients and payers.

There are also notable gaps in access associated with each approach, according to Patty Taddei-Allen, PharmD, MBA, a clinical assistant professor at the University of Florida and panelist at the Academy of Managed Care Pharmacy (AMCP) session, “The Fine Print of Affordability: What Employers and PBMs Need to Know About Cost-Shifting Strategies.”

“When we're thinking about the co-pay maximizers and the accumulators, what they do is they reside within the existing benefit,” she said. “And what they do is they're in essence just shifting some of the costs, and those patients are going to be exposed to those costs.”

In these models, the overall benefit design remains unchanged, Taddei-Allen emphasized, meaning manufacturer rebates and plan structures are largely preserved. However, this also means patients may still face high out-of-pocket costs at different points in the year, depending on how assistance is applied.

By contrast, AFPs take a different approach by removing certain high-cost drugs from the formulary altogether. Patients are then redirected to external funding sources, such as manufacturer assistance programs, which can reduce plan liability but may introduce uncertainty in access and continuity of care. This shift can also result in lower rebate yields for plan sponsors.

“And so, these considerations need to be thought about as you're evaluating which type of program you might be implementing,” she said.

These evolving strategies ultimately underscore the growing complexity of pharmacy benefit design and the need to balance cost containment with patient access and transparency.

“One thing that these programs really do is it allows you to really see what some of those financial relationships are and how the different stakeholders interact with one another,” Taddei-Allen said.