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)
Download a PDF of the Evaluation Criteria Checklist