Evaluation Criteria Checklist
Access to Care Coordination
- Advanced primary care
- Concierge Member Services, navigation, and advocacy support
- Direct contracts and Centers of Excellence for complex care needs
- Health care visits on the clock
- Robust mental/behavioral health benefits
- Clinical justification for off-formulary drugs, fair appeals
- No mid-year formulary reductions; formulary additions allowed
Affordability
Total Spend
For All Groups, Both Self-Funded and Fully-Insured
- Admin fees are fixed PEPM or per-transaction v. “estimated” or “adjustable”
- Full ownership of claims data (medical/Rx)
- Robust reports, including net PEPM cost
- Effective internal and external claims audits
- Reasonable capitation/value-based fees
- Member steerage to high-value care through benefit design
- 501(r) integration
Member Spend
- High-value care is free or near-free
- Apply cash or low-cost out-of-network prices against patient deductible
- Shared savings programs for choosing lower-cost, high-quality care
- No copay accumulators and similar programs
- 501(r) assistance for all eligible member OOP costs
- Price transparency tool
- Billing quality metrics adopted by plan providers
- No HDHP (unless significantly funded via HSA or reimbursed via HRA)
- Self- or level-funded explored and implemented where actuarially advantageous
For Self-Funded Or Partially Self-Funded Groups:
Vendor Contracts and Conflicts of Interest
- Carveouts permitted for PBM/stop-loss
- Direct contracting
- Predictable, meaningful fee structure in vendors
- Stop-loss rates account for cost-control plan design
- Stop-loss financial independence from other vendors
- Broker transparent comp disclosure
- Broker puts some or all of fee at risk for results
Rx-Specific Contracts and Conflicts of Interest
- No carrier/TPA conflicts with PBM (or disclosed and alternative PBM allowed)
- No PBM conflicts with specialty pharmacy or mail-order (or disclosed and alternative permitted)
- Rebates and other concessions disclosed and passed through
- Generics and biosimilars incentivized
- No pay-for-play formularies
- No spread pricing
- PEPM Rx spend = bottom line for evaluating financial performance
- Guaranteed AWP discounts and rebate minimums
- Reasonable PBM fee structure
- Formulary flexibility
- Alternate sourcing (outside PBM, international, direct contracts, etc)