Frequently Asked Questions

Most self-funded plans run on unbundled ecosystems—TPA, PBM, navigation, wellness, point solutions, and specialty programs. The key is a unified data hub that consolidates claims, pharmacy, and engagement data and drives coordinated workflows. With a single source of truth, HR can align vendors around shared metrics, ensure timely interventions before costs escalate and eliminate conflicting or siloed actions.

Stronger guarantees include: • Transparent pass-through pricing and fee disclosure • Rebate/retention transparency down to NDC • MAC list clarity • Clinical program performance standards • Claims accuracy and turnaround times • High-cost claimant escalation requirements HR must enforce guarantees with clean data, monthly monitoring, and audit-ready reporting—not just annual reviews.

A defensible scorecard includes metrics across: • Cost: PEPY, trend vs. benchmark, avoidable spend • Quality: evidence-based care compliance, chronic condition control • Access: network performance, steerage success • Experience: engagement, satisfaction, navigation efficiency These KPIs help align HR, Finance, vendors, and leadership on the same priorities.

True cost containment comes from plan optimization, not cost-shifting. Key levers include: • Reducing waste and low-value care • Early high-cost claimant intervention • PBM optimization and specialty drug management • Steering to high-quality, lower-cost providers • Improving vendor performance and alignment These actions protect employee affordability while lowering total spend.

Signals to monitor include: • Rising specialty pharmacy utilization • ER visits without follow-up • Multiple prescribers or drug interactions • Gaps in chronic condition management • Non-adherence to evidence-based pathways • Missed preventive screenings Timely alerts help HR intervene during the care journey, before small issues become catastrophic spend.

Evaluation should include: • Total cost of care before/after enrollment • Adherence and clinical outcomes • Avoided hospitalizations or complications • Trend vs. benchmark populations • Vendor promises vs. actual results Using client-specific, claims-based evaluation ensures ROI is real—not vendor-modelled.

A strong cadence includes: • Real-time alerts for threshold breaches • Monthly variance reporting • Quarterly strategic reviews • Annual vendor scorecards • Corrective action plans when performance slips This ensures HR stays ahead of risks—and ahead of Finance's questions.

ROI should include: • Reduced waste • Avoided high-cost claims/events • Trend compared to local and national benchmarks • Clinical improvements • Engagement and satisfaction gains • Total cost of care impact over time Finance-ready ROI builds trust with CFOs and supports data-driven budgeting.

HR should secure: • Full access to claims, pharmacy, and fee data • No gag clauses or restrictions on analysis • Real-time eligibility and claims feeds • Portability across TPAs, PBMs, and point solutions • Cooperation clauses for data sharing This ensures transparency and continuity—even when vendors change.

Core steps include: • Objective vendor evaluations (don't rely on vendor self-reporting) • Reviewing alternatives and fees • Regular performance monitoring • Documenting all decisions and rationales • Holding vendors accountable to measurable outcomes Documentation and transparency are key to fulfilling fiduciary obligations.

A defensible process includes: • A formal committee structure • A defined meeting cadence • Scorecards and KPIs • Annual reviews and corrective actions • Minutes and decision logs This protects the organization—and HR leaders personally.

HR can assess reasonableness by requiring: • Pass-through pricing • Rebate breakdowns at the NDC level • MAC list disclosure • Spread and fee reporting • Annual independent audits Transparency is non-negotiable under fiduciary standards.

CAA/NSA introduces requirements for: • RxDC reporting • Gag-clause attestations • Machine-readable files • Advanced EOB • Surprise billing compliance HR must ensure contract language and workflows support these obligations.

Minimum requirements include: • Encryption standards • Access controls and logging • Breach notification timelines • Right-to-audit • Subcontractor oversight • Data retention and destruction policies • Use and disclosure requirements Security diligence is part of fiduciary governance.

Consistent definitions across all documents are essential. HR should ensure alignment on: • Eligibility • Exclusions • Accumulators • Coordination of benefits • Stop-loss provisions • Vendor obligations Misalignment leads to denied claims, disputes, and fiduciary exposure.