The Process | Insurance | Benefits | Compliance Case Study


Our Client: Staffing Company with 250 employees was uncomfortable with their partially self-funded plan’s exposure to high cost specialty medications, but didn’t know how to legally reduce their exposure.
The Challenges:
  • Employee specialty medication costs were rising at an unacceptable rate.
  • Their Third Party Plan Administrator (TPA) was resistant to excluding specific drugs or classes of medication.
  • The Staffing Company still wanted to provide access to critical specialty medications if all other options failed.
  • Implemented a specialty carve-out program that allowed employees to obtain certain specialty medications via foundation grants or manufacturer assistance programs for no cost to member or plan.
  • Drafted ACA compliant Amendment to Summary Plan Description that was acceptable to Stop Loss carrier, TPA, and allowed the member and group a safety net if assistance programs disappeared to regain coverage through the plan.
  • Specialty medications as a percent of RX spend was reduced from 21% to less than 3%.
  • Annual plan savings due to carve-out program implementation of $145K.