Originally published by our sister publication Specialty Pharmacy Continuum
By Karen Blum
The use of alternative funding programs (AFPs) significantly reduces the likelihood of beneficiaries accessing needed medications, increases time to treatment, and is associated with more gaps in therapy and adverse clinical outcomes compared with traditional pharmacy benefits.
Pharmacists at a dozen health systems presented these new results about AFPs—for-profit third-party vendors used by self-funded employer plans that carve out certain medications as “nonessential health benefits” and attempt to obtain medication from non-health plan soiurces—in a presentation at AMCP Nexus 2025, in National Harbor, Maryland (poster 138).
AFPs attempt to obtain medications from non-pharmacy benefit sources or through low-cost alternative pathways, said lead study author Autumn Zuckerman, PharmD, BCPS, CSP, the director of health outcomes and research at Vanderbilt Specialty Pharmacy, in Nashville, Tennessee. “Surveys show AFPs are expanding among small and medium-sized employers, but the AFP process causes treatment delays and increased anxiety for patients,” she said.
In a prospective randomized cohort study, Dr. Zuckerman and pharmacist colleagues at 11 other health systems followed 260 patients enrolled in an AFP. As a matched control (non-AFP), they followed 500 patients who were enrolled in a traditional pharmacy benefit program, randomly selected at a 1:2 ratio within each site. Patients were followed from January 2024 through August 2025. The primary outcome was medication access, defined as the preferred medication or an appropriate alternative being obtained by the patient. Secondary outcomes included referral outcome, time to access (from referral to receiving medication), therapy gaps, and poor clinical outcomes during the access process. Investigators used a mixed-effects logistic regression model to analyze medication access and clinical outcomes.
The median patient age was 49 years for AFP enrollees and 53 for non-AFP enrollees, most (80%-83%) participants were white, and about 44% in each group were new to therapy. Clinical areas represented in both groups included rheumatology (24%), hematology/oncology (19%), and gastroenterology/irritable bowel disease (16%).
Overall, 83% of AFP patients and 95% of non-AFP patients accessed their prescribed therapies. Non-AFP patients were 3.8 times more likely to be able to access their prescribed therapies (odds ratio [OR], 3.8; 95% CI, 2.0-7.2; P<0.001). “You might think that doesn’t seem clinically significant, but if you think that each one of these patients is somebody who’s on cancer treatment or an inflammatory bowel disease treatment or a rheumatology treatment, not being able to get your medication is a really big deal,” Dr. Zuckerman said.
Among non-AFP patients, 89% of prescriptions were filled by a U.S. pharmacy, 5% by a manufacturer patient assistance program (PAP), and 3% were changed to the medical benefit. Among AFP patients, 33% of prescriptions were filled by manufacturer PAPs, 31% by an AFP-preferred or “shell” U.S. pharmacy, and 16% by a non-U.S. pharmacy. Shell pharmacies are those based in the United states, but procure medication from overseas. The percentage of PAP-filled prescriptions for AFP patients is notable, Dr. Zuckerman said, because these are programs meant for patients who don’t have insurance, yet one-third of insured patients were going through these programs.
In time to access medication, non-AFP patients received treatment 3.4 times faster than AFP patients, with a median of eight days compared with 32 days (hazard ratio [HR], 3.4; 95% CI, 2.8-4.0; P<0.001). For patients already on therapy and needing a refill, 35% of AFP patients had a gap in treatment compared with just 2% of non-AFP patients. AFP patients were 47 times more likely to have a treatment gap (OR, 46.8; 95% CI, 16.8-129.9; P<0.001). And, 65% of AFP patients were required to apply for a PAP, 50% of which were denied due to their AFP enrollment.
Finally, 28 AFP patients (11%) had a poor clinical outcome such as disease progression or worsening compared with seven (1%) non-AFP patients. Overall, AFP patients were 9.2 times more likely to have a poor clinical outcome during the access process (OR, 9.2; 95% CI, 3.96-21.36; P<0.001).
The clinical information was only pulled from electronic health records, Dr. Zuckerman noted, so it’s possible these figures could be underestimated.
Dr. Zuckerman reported no relevant financial disclosures.
