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Across commercial coverage types, health insurers design benefits and reimbursement strategies (like formularies) to manage health care quality and utilization, and to limit spending.  

Over the past decade, plans have adopted new strategies to reduce their prescription drug costs. Two of these strategies, known as accumulator adjustment programs (AAPs) and copay maximizer programs (maximizers), apply when a plan enrollee uses some type of third-party assistance to help meet their plan’s cost-sharing requirements. The third approach, alternative funding programs (AFPs), removes specific medicines from insurance coverage entirely and instead directs patients – typically aided by a vendor – to charitable assistance programs originally established to serve uninsured patients.  

These practices all determine whether and when affected patients can meet deductibles and/or annual coverage limits and may cause coverage uncertainty for patients throughout the year. 

Payer Survey 

Avalere Health surveyed commercial plan decision-makers regarding current and expected adoption of these three strategies. The survey found that all three program types – AAPs, maximizers, and AFPs – are widely and increasingly used by commercial plans. More than 60% of the programs included in the survey were implemented within the last four years.  

As policymakers and other stakeholders consider the impact of these plan-focused cost-avoidance strategies on patients, it is important to keep data limitations in mind. Notably, survey respondents mentioned a lack of data tracking on key measures, including patient adherence, outcomes, satisfaction, and costs. Respondents cited cost containment and premium reduction as plans’ primary motivations for program adoption, but these metrics were not verified by additional data analysis.