Key Clinical Summary

• Copay accumulators and maximizers alter cost-sharing structures but are associated with reduced adherence and increased treatment discontinuation in some studies.
• Alternative funding programs (AFPs) may reduce gross drug spend but introduce delays, administrative complexity, and potential loss of rebate value.
• Evidence suggests cost-shifting strategies can increase downstream medical costs and patient burden, underscoring the need for comprehensive financial and clinical evaluation.

At the 2026 Academy of Managed Care Pharmacy (AMCP) conference, experts highlighted the growing use of cost-shifting strategies—copay accumulators, maximizers, and AFPs—to manage rising specialty drug costs. The panelists noted that while these strategies may generate short-term savings, they often redistribute financial burden across stakeholders, with important implications for adherence, patient outcomes, and total cost of care.

Mechanisms and Market Drivers of Cost-Shifting Strategies

Patti Taddei-Allen, PharmD, University of Florida) and Billy Schnell, PharmD, Albarca Health, outlined the structural and operational differences among cost-shifting strategies. Specialty drug spending has risen 43% since 2016, reaching approximately $301 billion in 2021. This increase is driving employers and payers to explore alternative benefit designs.

Copay accumulators prevent manufacturer assistance from counting toward patient deductibles or out-of-pocket maximums, while maximizers spread assistance across the benefit year to fully capture available manufacturer support. Both approaches maintain formulary coverage but alter cost-sharing dynamics.

In contrast, AFPs exclude certain drugs from the benefit and redirect patients to external funding sources such as manufacturer assistance programs or charitable foundations. These programs introduce additional administrative steps and eligibility requirements, often tied to federal poverty level thresholds.

Evidence presented included a retrospective analysis of 603 patients with autoimmune conditions, showing that copay accumulator programs were associated with 233 fewer prescription fills per 1000 patients and a 20-percentage-point increase in treatment discontinuation. Additionally, a study on maximizers found a 51% increase in patient liability for non-drug medical services, suggesting spillover effects beyond pharmacy costs.

AFPs were associated with significant delays in therapy initiation. A patient survey reported a mean wait time of 68 days for medication access, with 24% of patients reporting worsened conditions due to delays.

Stakeholder Perspectives and Real-World Evidence

According to Dr Taddei-Allen, affordability depends on perspective—employers focus on net spend, while patients prioritize out-of-pocket costs and timely access. She emphasized that “cost containment does not eliminate costs,” but rather shifts them across stakeholders and timeframes.

Dr Schnell highlighted the importance of distinguishing between gross and net savings, noting that AFP projections often overlook rebate displacement, vendor fees (typically 20%-35% of projected savings), and operational risks.

Both speakers stressed that patient experience is frequently impacted. Increased complexity, delays, and communication gaps can lead to confusion, abandonment, and disengagement from care.

The panel also noted growing regulatory scrutiny, including state-level restrictions on accumulator programs and federal concerns regarding international drug sourcing within AFP models.

Financial, Clinical, and Operational Considerations for Payers

For payers and managed care stakeholders, these findings underscore the need for comprehensive evaluation of cost-shifting strategies. Financial modeling should incorporate rebate loss, vendor fees, eligibility risks, and potential downstream medical costs.

Equally important is assessing patient impact, including adherence, access delays, and administrative burden. Employers must also consider compliance obligations under Employee Retirement Income Security Act of 1974 (ERISA) and evolving regulatory frameworks.

Key Takeaways for Benefit Design and Policy Evolution

Cost-shifting strategies such as accumulators, maximizers, and AFPs offer potential short-term savings but introduce clinical, operational, and regulatory trade-offs. Ongoing research and real-world evidence will be critical to guide benefit design decisions and optimize outcomes for patients and payers alike.

Reference

Taddei-Allen P, Schnell B. The Fine Print of Affordability: What Employers and PBMs Need to Know About Cost-Shifting Strategies. Presented at: AMCP 2026; April 13-15; Nashville, TN.