Hubs East 2025: The Patient Access Landscape

Image Credit: Nicholas Saraceno

The final day of Informa’s Access USA conference arrived quickly, and I decided to attend a session along the Hubs East track focused on “The Changing Landscape of Patient Access—Accumulators, Maximizers & Alternative Funding.”¹

Featuring Meredith McDonald, director of patient access, Exelixis; Kimberly Westrich, National Pharmaceutical Council; and Vicki Karlan, US market access strategy lead, Pfizer, the presentation focused on multiple concepts including:

• Copay accumulators, maximizers, and alternative funding programs’ (AFPs) impact on patients and manufacturers (McDonald)
• Impact of cost-shifting programs on patients, employers, and the health system (Westrich)
• Keeping up-to-date state and federal actions (Karlan)

First off, it’s important to note that the goal of copay assistance is to assist patients with their out-of-pocket (OOP) drug costs, but accumulators can prevent assistance from counting toward a patient’s deductible or OOP maximum. As a result, this can lead to patients receiving a copay shock, not knowing they are even signed up for an accumulator to begin with. Enforcement of copay accumulator bans by state and federal governments have been limitedly enforced.

Meanwhile, co-pay maximizers are implemented by payers and pharmacy benefits managers (PBMs). They alter the patient’s benefit design to instead use the maximum annual co-pay contributions, separate of the patient’s yearly OOP max.

“Unfortunately,” said McDonald, “maximizers have gotten a lot trickier the last year or so, and they're not as forthcoming in picking up the patient's out of pocket costs.” Part of this trickery, she noted, refers to plans accepting the copay card and distributing it over 12 months, but after realizing that patients might be on a drug for an entire year, plans began to front load the patient assistance in one or two fills. In essence, plans are maximizing the value from copay assistance programs by altering a patient’s cost-sharing to the greatest amount of available assistance.

As for AFPs, they are considered a newer type of carve-out offering within a plan design, where specialty drugs can be identified at no cost, which is often known as a specialty carve-out.

Cost-shifting programs could harm patients, while also raising ethical concerns. In fact, studies have found that copay accumulator programs can negatively affect patient care and the health system itself via unexpected OOP costs, reduced medication adherence, and exacerbated health inequities.

An interesting study that Westrich revolved around patient experiences with their employer, AFP vendor, and application processes—not only was the average reported wait time to receive medication two months, but 24% of patients reported that delays in receiving their medication caused their condition to worsen, while 64% of patients said the wait to receive meds led to stress and/or anxiety.

As referenced earlier, there has been difficulty with enforcing copay accumulator bans—Karlan explained that as of February 2025, 21 states, Puerto Rico, and DC, have all enacted laws, but those laws only apply to state-regulated plans, such as individual, small group, and large fully-insured groups. However, positively speaking, there 13 more states looking into the implementation of accumulator bans, representing 26 bills.

Reference

1. McDonald M, Westrich K, Karlan V. The Changing Landscape of Patient Access—Accumulators, Maximizers & Alternative Funding. March 20, 2025. Hubs East 2025. Philadelphia.