(136) Unmasking Alternative Funding Programs- Patient Outcomes and Prescription Journey

Background: : Alternative funding programs (AFPs) exclude high-cost medications from patients’ pharmacy benefits and seek to obtain medication through alternative sources. Research describing the methods and outcomes of AFPs is needed.

Objective: : Evaluate the prescription journey and patient outcomes in patients forced to use an AFP.

Methods: : A multisite prospective cohort study including patients identified as enrolled in an AFP with a specialty medication referral sent to a health-system specialty pharmacy (HSSP) in 2024 was conducted. Data were collected by each site and imported into a shared data warehouse for analysis. Patients were followed until referral outcome was determined.

Results: : There were 252 patients identified to be in an AFP in 2024 among 12 sites. Overall, 80% of new and 93% of continuing therapy patients were able to access the prescribed therapy or an alternative in a median of 29 days (IQR [interquartile range] 18, 57) and 33 days (IQR 12, 52) from referral, respectively. AFP enrollment was most commonly recognized by the HSSP after prior authorization (PA) or appeal approval followed by forced AFP enrollment (28%), after insurance denial with forced AFP enrollment (21%), or when no PA/appeal option existed and patients were directed to manufacturer patient assistance programs (PAPs) (18%). A PA and/or appeal was submitted for 73% and 28% of referrals, respectively. 65% of patients applied for manufacturer PAP; 54% were denied, most commonly because of their enrollment in an AFP (51%). A courtesy fill was required for 16% of patients and 12% required a sample during the access process. Patients eventually had their medication filled through PAP (32%), the original or an alternative medication filled by a preferred US pharmacy (30%) or filled internationally (14%). Fewer patients had to change insurance to get approved (5%), were lost to follow-up (5%), or used internal HSSP grants for coverage (2%). 36% of patients experienced a gap in therapy during the access process. 11% of patients had documented poor clinical outcomes while awaiting therapy. 7% of patients contacted their human resources department due to access issues.

Conclusions: : AFPs increase complexity in accessing life-altering specialty medication therapies, take advantage of manufacturer assistance programs meant for uninsured/underinsured patients, and often result in treatment gaps that can lead to poor clinical outcomes.

Sponsorship:: None