TABLE 2.

Recommendations to Care Teams to Navigate Cost-Shifting Strategies

Patient education
Provide a patient-level explanation of copay accumulator programs, copay maximizer programs, and AFPs	Educate patients on the structure, process, and function of programs and what to expect at each step of the process. When a plan has partnered with a third-party program for maximizer implementation, patients may not be aware of the requirement for enrollment or what benefit the program provides.
Provide educational resources	Inform or provide the patient with resources from professional organizations such as the American Society of Clinical Oncology, Crohn’s and Colitis Foundation, and Arthritis Foundation that explain accumulator programs.
Set medication access timeline expectations	Care teams should set expectations with patients that they are likely to experience delays in accessing therapy if they are enrolled in these plans, particularly in AFPs, given the extensive access process.
Encourage patients to understand benefits design at enrollment	Educate patients on thoroughly reviewing insurance benefits designs to understand a plan’s premiums, medical and pharmacy deductibles, and if a copay adjustment program exists. Patients should speak with their health care provider and pharmacist about alternative treatments that might be covered by their plan or consider searching for a new plan during open enrollment that provides better coverage for their medication. If coverage options are limited by their employer, patients should talk with their benefits manager about improving access to their medication. Patients who are forced to use copay accumulator, maximizer, or alternative funding programs should provide feedback to their human resources department regarding their experience with these programs.
Care team action
Calculate and communicate patient cost of therapy with and without manufacturer assistance	When enrolling patients in copay cards, the care team should document the maximum allowable amount of the copay card and, if possible, estimate if it will be enough to cover the patient’s OOP cost through the full course of treatment or year. If not, the care team should make the patient aware of how much OOP cost is anticipated after the copay card is exhausted.
Quickly respond to denials	Notify patients of what steps to take when they face coverage or manufacturer assistance denial to include reaching out to their care team as soon as possible.
Identify AFP enrollment	Though challenging, the following may help the care team identify whether a patient is enrolled in an AFP: ◦Medication denial ahead of PA submission—The care team may receive a denial letter prior to PA submission, potentially triggered by the pharmacy running a test claim. ◦PA denial letter—The denial letter often lacks a section describing the appeals process or contact information for an appeals department. ◦Insurance formulary carve outs—The insurance plan will not list formulary alternatives to the prescribed medications or state that all specialty medications are excluded. ◦Third-party representative—Early on, a third-party representative may contact the care team as the third-party “advocate” and insist on being the liaison between the patient and care team to facilitate enrollment in the manufacturer’s PAP.
Coordinate care and communication	During the medication access process, patients who are continuing therapy may be at risk for gaps in treatment. The care team should help patients obtain medication via override fills (approved by insurance), samples, or quick start vouchers if available to prevent lapses in therapy. The care team will likely need to serve as a navigator and educator for patients throughout the access process to help patients successfully complete necessary requirements to obtain treatment.
Care team action
Remain current on legislation status related to these programs	Health care providers and pharmacists should be aware of state and federal legislation related to copay accumulator, maximizer, and alternative funding programs. Disease state coalitions such as the Coalition of State Rheumatology Organizations can be a good resource for identifying current legislative efforts.

AFP = alternative funding program; OOP = out-of-pocket; PA = prior authorization; PAP = patient assistance program.