Why would a stop loss carrier cover a loss when there was not one? Would it surprise you they routinely do that?
Prescription drug rebates average 30-40% of a typical plan’s Rx spend inclusive of generic and brand name drugs. Total Rx spend averages 25-45% of a plan’s spend these days which can amount to a lot of money over a year’s time. Specialty drugs can cost hundreds of thousands of dollars a year for just one member.
Stop loss carriers don’t track Rx rebates. They track gross paid amounts reported by your PBM. If Rx is covered by your stop loss policy chances are good you are getting paid for claim dollars that have already been returned to you.
If you could change your stop loss policy to cover only net paid Rx claims you might save money on your stop loss premium. If your gross Rx spend is 30% of your total plan spend, and Rebates average 30%, your risk factor drops 9%.
