Many prescription benefit managers (PBMs) operate their own mail service pharmacies, specialty providers, and even own retail stores that handle a large portion of prescription fulfillment. PBMs frequently encourage members to use their mail service by offering various incentives, such as reduced copays or additional benefits. While these incentives can create convenience and potential savings for both the plan and its members, they must be structured carefully. If copays are set too low, the plan may end up paying more for mail service claims than it saves, resulting in a financial loss.

​

HealthLinX (HLX) works with you to design a benefit structure that aligns with your financial goals while preserving member value. We provide a comprehensive approach that includes:

​

• Break-Even Analysis: Our team meticulously analyzes your plan’s actual claim data, along with its unique reimbursement arrangements, to determine the exact break-even point where mail service becomes cost-effective for the plan. This calculation considers all variables, such as medication costs, dispensing fees, and current member copays, ensuring recommendations are data-driven and specific to your plan.

• Financial Assessment: Beyond just identifying the break-even point, we examine how different member incentives or copay adjustments could affect your overall costs and savings. This financial modeling helps you understand the direct impact of proposed changes. We present various scenarios to highlight the range of possible financial outcomes, empowering you to make adjustments that benefit both the plan and its participants, while avoiding hidden losses.

• Informed Decision-Making: With our detailed analysis and clear reporting, you gain deep insight into the financial health of your benefit design. We translate complex data into actionable recommendations and provide guidance on how each adjustment could affect member satisfaction, plan competitiveness, and overall spending. This empowers your team to make thoughtful, strategic decisions that support the long-term sustainability of your plan.

​

By leveraging HLX’s expertise and comprehensive analysis, you can confidently structure your mail service and specialty pharmacy benefits to maximize value, minimize risk, and support the evolving needs of both your organization and its members.