By: Kevin Kobielski, President of Navion
As specialty drug costs continue to rise, alternative funding programs like Manufacturer Assistance Programs (MAPs), Patient Assistance Programs (PAPs), and Copay Assistance Programs (CAPs) are gaining attention as ways to ease the burden. But while these programs can deliver meaningful savings, they’re not always straightforward—and they’re rarely one-size-fits-all.
To make strategic decisions, employers and their partners need more than definitions. They need clarity on how these programs work in practice, what trade-offs they may involve, and when they’re worth the complexity.
A Quick Guide to MAP/PAP, and CAP
- MAP/PAP (Manufacturer/Patient Assistance Programs):
PAPs are typically funded by manufacturers are designed to support uninsured patients or those who meet specific income-based eligibility thresholds—often tied to a percentage of the Federal Poverty Level. These programs can generate direct savings for employer health plans and their members. They also can offer meaningful support for members facing high out-of-pocket costs. In some cases, vendors may assist eligible members in accessing MAP/PAP resources, particularly when certain high-cost drugs are carved out of the pharmacy benefit. These programs can either be provided by the PBM or a separate vendor if specialty is carved out.
- CAP (Co-pay Assistance Programs):
CAPs provide manufacturer-funded copay cards or coupons that help reduce out-of-pocket costs for members using brand-name medications. These programs can be a valuable affordability tool, especially for high-cost therapies. To ensure both members and the plan benefit, employers often implement copay accumulator or maximizer strategies—structures that help align manufacturer assistance with broader plan goals. When thoughtfully designed, these programs can improve access while managing long-term cost impact.
When These Programs Make Sense—and When They Don’t
These programs can be powerful levers in a cost-containment strategy—but only when used in the right context.
Key considerations include:
- Utilization: Are enough members eligible or likely to benefit to justify vendor fees and operational complexity?
- Rebate Impact: Participating in MAP or PAP programs can affect the rebates you receive on certain high-cost drugs. That doesn’t mean the strategy isn’t valuable—but it does mean savings should be evaluated holistically, weighing vendor fees, member impact, and potential rebate changes together to get a clear picture of net value.
- PBM Flexibility: Will your PBM allow these programs to be layered in, or will participation trigger penalties or contract conflicts?
- Member Experience: Will these programs increase member burden, delay fulfillment, or disrupt adherence?
- Cost: Is it a percentage of savings model vs a flat PEPM or PMPM.
For example, we found that one client who layered in a MAP program expecting significant savings and actually saw limited benefit—only a small number of members qualified, and the resulting rebate losses offset much of the gain. When we shifted those members back to standard specialty fulfillment, overall performance improved and the plan saw better results with fewer complexities.
On the other hand, another client with a high concentration of eligible members saw substantial savings by incorporating MAP into their benefit design. By targeting specific medications and aligning the program with their PBM contract, the employer saved hundreds of thousands annually—without disrupting member access or care continuity.
The Bottom Line
MAP/PAPs, and CAPs aren’t silver bullets—they’re specialized tools. Sometimes, they can help employers exponentially increase savings. But when they’re not used strategically, they can create confusion, disrupt care, or leave savings on the table.
That’s why every alternative funding strategy should be evaluated against your actual claims data, your PBM contract, and your long-term goals. In today’s market, savings are out there—but only if the solution fits the strategy. Working with a partner that understands the nuances and complexity of pharmacy benefit design can help ensure you’re not just choosing a program, but implementing the right one for your population.
