Plan Hacks: 12 Ways to Free-Marketize your Plan

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RX Costs

  • Encourage employees to “shop” for their prescriptions; costs can vary widely between pharmacies, even with a PBM.
  • Many PBM contracts make the cost of a drug higher than if it was bought with no contract in place.
  • If employee pays cash for lower-cost RXs, structure your Plan to reimburse these purchases.
  • Cover the cost of RXs purchased by the employee from their DPC; generally at wholesale prices.
  • Check out free market pharmacies.

Durable Medical Equipment

  • Many pieces of durable medical equipment (crutches, breast pumps, CPAP machines, etc.) can be bought for much less on the open market than through the network.
  • Incentivize your participants to shop for DME based on price!
  • Structure your Plan to allow reimbursement if your employee finds their equipment online or through a non-network provider and pay it at 100% (HDHP rules would still apply).

Out-of-the Box Tips

  • Cover over the counter drugs! Often, when commonly used heartburn and allergy drugs go OTC, patients switch to another RX because it’s no longer covered by their health Plan.  You can cover these OTC drugs at 100% to lower your RX spend! Why stop covering it when it gets cheaper? (HDHP rules would still apply)
  • Work directly with high value, low cost lab providers and incentivize your employees to use them.
  • Place dollar caps or a reference based pricing cap on services that have the most unpredictable, and often incredibly high, cost; such as air and ground ambulance, implantable items, interoperative nerve monitoring, dialysis, and more. If an employee gets balanced billed, you can step in and help negotiate a more reasonable reimbursement.
  • Many out-of-network physicians and facilities are actually high value! Penalizing patients for using a ‘good guy’ even though they are a better deal is not in your Plan’s best interest. Eliminate out-of-pocket penalties for non-network providers and allow your employees to shop for the best value.