(138) Forced Alternatives: The Impact of Alternative Funding Programs on Specialty Medication Access vs. Traditional Coverage

Background: : More employers are requiring employees who need high-cost medications to use alternative funding programs (AFPs), which aim to secure medications through non-insurance sources.

Objective: : Evaluate specialty medication access outcomes in patients required to use an AFP versus those using traditional pharmacy benefits.

Methods: : This prospective cohort study included patients referred to a health-system specialty pharmacy in 2024, enrolled in an AFP from 12 sites. As a matched control (non-AFP), patients enrolled in traditional pharmacy benefits were randomly selected with 1:2 ratio (or all patients were included if the ratio is smaller than 1:2) within each site, using matching criteria of clinical area and therapy status (new vs. continuing medication). The primary outcome was medication access, defined as the referred medication or an appropriate alternative being covered. Secondary outcomes included referral outcome, time to access (from referral to receiving medication), therapy gaps, and poor clinical outcomes during the access process. A mixed-effects logistic regression model was used to analyze medication access and clinical outcomes, while a mixed-effects ordinal logistic regression model evaluated time to access.

Results: : A total of 754 patients were included (AFP=252, non-AFP=502). Median age was 52years (IQR 39, 62); 81% were white, and 44% were new to therapy. Common clinical areas included rheumatology (24%), oncology/hematology (19%), and GI/IBD (16%). AFP patients were significantly less likely to be able to access their prescribed medication (OR 0.3 [CI 0.17, 0.54], p< 0.001); 87% of AFP vs. 93% of non-AFP patients accessed therapy. Referral outcomes differed: AFP patients received medications via manufacturer assistance (32%), an AFP-preferred U.S. pharmacy (30%), or non-U.S. pharmacy (14%), while 88% of non-AFP patients used a U.S. pharmacy and 5% filled through manufacturer PAP. More than half of AFP patients applied for manufacturer assistance programs (65% vs. 10%). AFP patients had 8.4 times the odds of having longer time to access medication (p < 0.001) compared to non-AFP patients; median 31 days (IQR 16, 54) vs. 8 days (IQR 4, 16). AFP patients had more treatment gaps and sample use than non-AFP (36% vs. 2%, and 12% vs. 2% respectively). Poor clinical outcomes were more frequent in AFP patients (11% vs. 1%) than non-AFP.

Conclusions: : Use of AFPs significantly reduces the likelihood of accessing therapy, increases time to treatment, and is associated with more therapy gaps and adverse clinical outcomes compared to traditional pharmacy benefits.

Sponsorship:: None