Plan Grader
Is your plan:
Fully insured
Level funded
Self funded
Other
Do you have unrestricted access to full claims data for your plan? *
Yes
No
Who is involved in your annual benefits review, planning and design process? *
HR
CFO
CEO
Other Executive Management
Employee Representatives
All of the above
N/A
Which of the following cost containment tools are in place today? *
Reference Based Pricing
Direct Contracting
Bundled Procedures
Centers of Excellence
Second Opinion Services
Transparency Tools
Employee Advocacy Service
N/A
Which Virtual Health options does your plan include?
Telemedicine
Virtual Primary Care
Virtual Behavioral Health
Virtual Physical Therapy
Online orders and scheduling of lab services
Direct Primary Care with 24/7 Virtual Services Included
N/A
Which major specialty area(s) does the plan have specific strategies for
Musculoskeletal
Cardiometabolic
Cancer
Transplant
Dialysis
Specialty drugs
Other
N/A
Which of the following applies to the plan's stop loss policy
The carrier has A or better rated paper.
The carrier has experience with and tools to project claims for transparent open network strategies, such as reference-based pricing.
The carrier proactively discounts for cost containment vendors and solutions.
The stop loss policy follows the underlying SPD for coverage disputes.
The contract includes at least a 12 month run out if the plan is utilizing reference-based price network model.
Specific Advance is included in stop loss policy.
The policy includes a no new laser rate cap.
The policy has at least a six-month rate lock-in to implement transparent open networks and educating members.
N/A
Which of the following is most accurate about the plan's stop-loss fees/commissions?
I shopped the stop-loss and can guarantee no additional fees or commissions
I didn't shop the stop-loss but can guarantee no commissions from any third-party
Other entities shopped the stop-loss and they charge fees or commissions for this service
Other
Does your plan have any Center of Excellence and/or 2nd opinion programs with meaningful incentives that benefit your employees?
Yes
No
Unknown
Does your pharmacy plan include the items listed below?
Ability to create custom formularies for your group
Contractual language that (1) you own your plan's Rx data and (2) that it cannot be sold or used in aggregate without your permission
Strict concurrent drug utilization reviews
Customizable prior authorization protocols
Quantity limits to proactively ensure proper utilization
Step therapy and starter dose programs to specifically ensure appropriate opioid dispensing (e.g., limits initial fills to a five-day supplies if state law does not already do so)
Full Rx rebates paid back to your company
Options for Zero member cost on options that save the company over $500 per Rx
Does your plan administrator (TPA) contractually agree to only receive revenue from admin fees paid?
Yes
No
Does your plan administrator (TPA) let you select the dollar amount threshold for auto-adjudicating claims?
Yes
No
Unknown
Does your plan use claims audits and/or payment integrity to minimize paying fraudulent claims and reducing identity theft?
Yes
No
Unknown
Name
Email
*
Phone
Employer / Plan Sponsor Name
*
State
Industry
Number of Eligible Members
Number of Enrolled Members
Annual Plan Spend
% Change from Previous Year
Notes/Comments about the plan or your answers
Name of Current Benefits Consultant, Broker, or Firm
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