Member Affordability

We Help Keep Member Cost Low.

The cost of health care is a major source of worry for plan members, especially for those enrolled in high deductible health plans (HDHPs). Because members in HDHPs are responsible for 100 percent of the cost of their care until they meet their deductible, for some that could mean thousands of dollars of out-of-pocket (OOP) costs each year. In a 2019 survey, the average single deductible was $1,655 with an annual coverage cost averaging $6,015. 

Helping lower member OOP costs can help improve adherence and satisfaction. In order to help members afford their medications and to support better overall outcomes we have developed a range of plan design strategies, such as point-of-sale (POS) rebates and preventive drug lists with $0 copay. RxZERO eliminates OOP costs for all categories of diabetes medications. Digital tools such as Real-Time Benefits and Savings Advisor provide greater cost transparency enabling members to make more informed decisions about choosing cost-effective medications.

Along with essential strategies such as formulary designs that promote the use of lower-cost drug options, these initiatives have helped lower OOP costs per 30-day prescription and reduced member cost share. Two out of three members spent less than $100 OOP in 2020.

We help keep drugs affordable for members

66% of members spent less than $100 out of pocket (OOP). Member average cost per 30-day supply was $9.72 in 2019, and only $9.63 in 2020. It decreased by $1.60 since 2015.

66% of members spent less than $100 out of pocket (OOP). Member average cost per 30-day supply was $9.72 in 2019, and only $9.63 in 2020. It decreased by $1.60 since 2015.

Want to learn how our solutions can help amplify your cost management? Contact us
Want to learn how our solutions can help amplify your cost management?
Contact us

Real-Time Benefits

Cost can be a barrier to adherence and higher OOP costs can force individuals to make tough choices about whether to fill a prescription. 

With our Real-Time Benefits solution, members can access prescription cost and the most updated benefit information – including their exact stage in the deductible – wherever they are: at the doctor’s office, the pharmacy, at home, or on the go. 


We advocate for the inclusion of $0 copay preventive drug lists in HDHPs, offer them to our own employees, and recommend clients adopt it for their plans. In addition, we have developed a solution specifically to address member OOP costs for diabetes, without raising plan costs.

RxZERO, a zero OOP diabetes plan design, eliminates OOP costs for all categories of diabetes medications without raising costs for the plan sponsor, or increasing premiums or deductibles. RxZERO takes away the need for members with diabetes to make difficult decisions about whether they can afford their medications. It can also contain or even lower, costs for payors, without the perceived trade-off they had to make before of increasing deductibles and premiums.

Fifteen percent of members spent more than $300 on medication with those using brand antidiabetic medication spending an average of $467 OOP annually.Kaiser HRET Survey of Health Plans, 2018. 2. CVS Health Book of Business, Commercial Cohort Clients, Jan 2018–Dec 2018 Enterprise Analytics, Feb 2019. And nearly 12 percent of those members using brand antidiabetic medications spend $1,000 or more annually on all diabetes medications. Our holistic care model combined with RxZERO, which helps ensure affordability and improve adherence, can lower costs and, more importantly, keep members on their path to better health.

Point-of-Sale Rebates

POS rebates help offset member OOP costs, especially during the phase when they are responsible for the full cost of the drug, by passing on the discount to members when they pick up their prescription at the pharmacy. Clients can choose to pass on part or all of the discounts we negotiate with manufacturers on their behalf.

In 2019, POS rebates helped members save more than $670 on average in OOP costs per eligible 30-day specialty prescription, and $155 per eligible non-specialty prescription. Average overall member savings was 42 percent – about $179 – in OOP costs per eligible 30-day prescription.Data being equalized from 30- and 90-day prescriptions and during the deductible phase. Actual results will vary based on plan design, formulary status, demographic characteristics and other factors.

Enhancements made for 2020 included the option to implement POS rebates for specific drug classes or lists, diabetes drugs, specialty treatments, a preventive drug list, or drugs with lower list but higher wholesale acquisition price. 

Want to learn more about how to help manage costs for your members? Ask Us

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