When Coverage Disappears: The Hidden Risks of Alternative Funding Programs for Patients on Biologics
Why Specialty Practices Must Pay Attention
For specialty practices delivering in-office biologic therapy, protecting patient access isn’t just about clinical excellence; it’s about navigating an increasingly complex insurance landscape.
One of the fastest-growing threats to stable patient care is the rise of Alternative Funding Programs (AFPs).
While marketed as cost-saving solutions, AFPs can abruptly remove coverage for specialty drugs, including the biologics your patients depend on, forcing them into a confusing maze of assistance programs.
The impact isn’t limited to patients; it ripples through your practice, creating delays, administrative burdens, financial uncertainty, and reputational risks.
At Altus Biologics, we believe it’s critical for private specialty practices to understand the risks AFPs pose, and to know they don’t have to face them alone.
What Are Alternative Funding Programs (AFPs)?
Alternative Funding Programs, sometimes called “carve-out programs” or “alternative drug coverage programs”, are third-party entities that remove high-cost specialty medications from a patient’s health plan.
According to one AMA’s issue brief on AFPs, these programs are often sold to self-funded plans as a cost-cutting measure, but in reality, they destabilize reliable patient access. Unfortunately, recent reports on AFPs highlight how these programs are rapidly expanding, despite creating significant risks for both patients and providers.
Here’s how they typically work:
- Patients continue paying insurance premiums, believing they’re covered.
- When it comes to specialty drugs (often biologics, but also other high-cost therapies), their plan refuses claims.
- Patients are redirected to manufacturer copay assistance or charitable foundations for support.
While this may appear like a harmless shift in funding, in reality, it undermines reliable coverage, as these programs were never intended to serve as long-term insurance replacements.

How AFPs Affect Patients on Specialty Drugs
The impact of AFPs on patients prescribed specialty therapies, including biologics, is immediate and often devastating:
Sudden coverage exclusions: Patients stable on a specialty drug suddenly learn it’s no longer covered; this can happen even in mid-treatment cycle.
Treatment delays: Patients must apply for copay or foundation grants, creating a weeks-long gap in treatment. For autoimmune and inflammatory conditions, these gaps can trigger painful disease flares.
Temporary fixes, not solutions: Assistance programs have eligibility limits, annual caps, and complex re-application requirements. They cannot replace consistent coverage.
Financial and emotional stress: Out-of-pocket shocks, paperwork overload, and the fear of losing access place heavy emotional strain on already vulnerable patients.

How Do AFPs Affect Specialty Practices?
Patients aren’t the only ones caught in the crossfire of these programs. For providers, AFPs create operational and financial headaches that extend far beyond individual patients:
Administrative overload: Staff spend hours managing AFP requirements, appeals, and patient reapplications, rather than providing care.
Disrupted continuity of care: Therapy interruptions mean more urgent visits, increased flare management, and greater liability exposure.
Financial instability: Buy-and-bill practices risk absorbing tens of thousands of dollars when AFPs deny or delay claims after administration. Additionally, healthcare economists estimate that some AFP vendors retain as much as 20–25% of the manufacturer’s assistance funds intended for patients, thereby further diverting resources away from patient care.
Reputational risks: Patients may wrongly blame their provider for denials or delays, which can erode trust and loyalty.

Why Does Reliable Coverage for Specialty Drugs Matter?
Specialty drugs, including biologics, are not luxury therapies; they are essential treatments that prevent disability, hospitalization, and long-term disease progression. Reliable coverage ensures:
- Patients receive uninterrupted care.
- Practices maintain predictable operations and revenue flow.
- Physicians make treatment decisions based on clinical evidence, not payer tactics.
AFPs dismantle this stability, replacing reliability with uncertainty, inefficiency, and risk.
Altus Biologics: Your Partner in Protecting Patient Access
Altus Biologics understands the challenges AFPs create for specialty practices, and we are here to help.
When you partner with us, you gain:
Expert benefits support: Our team manages benefit verification, prior authorizations, and financial assistance coordination to reduce administrative strain on your staff.
Appeals and reimbursement guidance: We work with practices to navigate payer hurdles and support billing and reimbursement processes, helping to minimize delays and claim denials.
Continuity of care focus: By tracking approvals and coordinating financial assistance, we help practices prevent treatment gaps and keep patients on therapy.
Operational and compliance expertise: From program implementation to workflow optimization, our services are designed to strengthen your practice and enhance patient satisfaction.
With Altus by your side, your practice is supported at every step, allowing you to focus on delivering life-changing biologic therapies to your patients.
Stay Proactive, Stay Protected
Alternative Funding Programs (AFPs) introduce instability, delay, and risk into the lives of patients and the operations of specialty practices. But you don’t have to navigate these payer challenges alone.
By staying proactive and partnering with Altus Biologics, you can safeguard patient access, reduce administrative strain, and maintain the clinical and financial stability your practice needs to thrive.
Frequently Asked Questions (FAQ)
Q: What is an Alternative Funding Program (AFP)?
An AFP is a third-party program that removes high-cost specialty drugs, including biologics, from insurance coverage and redirects patients to temporary assistance programs.
Q: Why do AFPs create treatment delays?
Patients must apply for grants or copay programs, which can add weeks of paperwork and waiting before therapy can resume.
Q: How do AFPs impact specialty practices?
They increase administrative work, disrupt care continuity, create reimbursement risks, and may erode patient trust.
Q: Do AFPs save patients money?
Not usually. While marketed as cost-saving for employers, patients often face higher costs, increased stress, and instability in coverage.
Q: Are patient assistance programs reliable replacements for insurance?
No. They are designed as temporary safety nets, not sustainable coverage solutions.
Q: How can practices protect themselves and their patients from AFP risks?
By conducting proactive benefits investigations, monitoring payer changes, and partnering with Altus Biologics for coverage support.
Q: What role does Altus Biologics play in addressing AFP challenges?
We reduce administrative burden, provide payer insights, assist with appeals, and safeguard patient access to specialty drugs, including biologic therapy.