What Really Drives Reimbursement in High-Cost Claims. When an employee experiences a high-cost claim, the immediate priority is always care and recovery. For self-funded employers, however, there’s another story unfolding at the same time. One that can have a significant financial impact.In part two of our latest Benefits Architecture edition, we’re taking a closer look […]

Stop-Loss Explained: How Employers Manage High-Cost Claim Risk. An area of health benefits strategy that is often misunderstood — or simply not explained in enough detail — is stop-loss insurance.As part of our Benefits Architecture series, we’re taking a closer look at stop-loss insurance, where it fits, and why it plays such a critical role […]

How Gene and CAR-T Therapies Are Changing the Cost of Employer Health Plans. Healthcare is entering a new era — one where certain diseases aren’t just managed, they’re potentially cured. For patients, this brings hope. For employers, however, it introduces a new level of financial risk.Our Benefits Architecture: Understanding the Life of a Medical Claim […]

The Million-Dollar Prescription: How Orphan Drugs Are Redefining Employer Risk. One employee, one prescription, and a decision that can affect a health plan strategy for the year ahead. A moment like this is one that many employers are encountering as specialized therapies become increasingly available.In Benefits Architecture: Understanding the Life of a Medical Claim, we […]

The $300,000 Difference: Managing the Cost of Specialty Drugs. It often starts with a diagnosis. An employee receives news that changes everything. It might be breast cancer, multiple sclerosis, rheumatoid arthritis, or another condition that requires advanced treatment.Their physician may recommend a specialty therapy – targeted medication designed to treat complex diseases more effectively than […]

Pharmacy Benefits Are Changing – Is Your Plan Ready? Many employer health plans appear financially stable – until they aren’t. Like the weather, conditions can look calm, then change quickly. One year, pharmacy costs may track closely with expectations. The next, a handful of high-cost prescriptions or a newly approved therapy can drive spending higher.A […]

Beyond the Coin Flip: Building Sustainable Healthcare in an Unpredictable Market. For many employers, healthcare has started to feel like a coin flip. Some years, you “win.” Claims are manageable and utilization trends are steady. Other years, you “lose.” A handful of high-cost claims hit, specialty pharmacy spend spikes, and costs surge. Yet, no matter […]

The GLP-1 Boom: A Breakthrough With a Growing Blind Spot. Medications like Ozempic, Wegovy, and Mounjaro are changing how many people manage type 2 diabetes, helping improve blood sugar control and, in many cases, support weight loss. The breakthrough has gained attention across the United States and made GLP-1 medications one of the fastest-growing drivers […]

Understanding Prior Authorization in Pharmacy Benefits. Heading to the pharmacy to fill a prescription only to be told it needs prior authorization can be frustrating for employees, but it is an important step in the healthcare system.In many pharmacy benefit plans, prior authorization is a built-in review step designed to ensure certain medications are safe, […]

Navigating Prior Authorization: A Checkpoint on Your Healthcare Journey. Just like planning a road trip, navigating a medical plan involves important checkpoints along the way. With employee benefits, one of the most important checkpoints is prior authorization, a step that helps ensure the care provided is safe, appropriate, and aligned with the plan’s benefits.Before certain […]