Self-Funded plan designs are becoming more common with rising medical costs. The financial risk has shifted to the employer vs. the carrier under fully-insured plans. Both plans access medical care through a provider network with established prices for services.

Our medical and pharmacy transparency programs empower participants to become better healthcare consumers by showing them how to get the best medical care from proven high-performance providers.

• Medical Advocate Program (MAP^®): When a participant speaks to a MAP^® Nurse Advocate, more than 40% of the time, the Nurse Advocate provides a different direction. It is shocking but true — all too often the participant’s self-diagnosis or medical need may have been incorrectly identified. Based on the participant’s location and medical needs, our Nurse Advocate and Research Analyst identify the top 5% to 10% of providers in their network. Through this unique approach, only 15% to 20% of physicians nationwide meet MAP ^® criteria. While that means 80% to 85% of physicians do not make the cut, it also means our participants get the very best medical care. MAP^® can assist with any type of medical care: primary care, specialist services, mental health, diagnostic tests, and second opinions. learn more » 
• MAP^® Rx: Our medical staff reviews the participant’s prescriptions to determine if they are taking the correct medications at the most cost-effective prices. Our programs can save participants money on thousands of name-brand and generic medications. We work with leading pharmaceutical companies to provide affordable solutions such as patient assistance programs, grants and other alternative resources. learn more »

• MAP^® UM/Precertification: In addition to providing medical necessity reviews, this program integrates with MAP^® to ensure participants make informed decisions about their medical care. MAP^® Precertification Nurses speak directly with the participant on every medical precertification. Through our medical review process, we also determine if the participant needs case management or our MAP® Rx program for prescription review. learn more »
   
• MAP^® Case Management: When a participant faces a serious illness, a Certified Case Manager (CCM) works directly with them and their family to ensure they understand how to navigate the healthcare system to achieve the best outcomes. Our resources include CCM Nurses, Research Analysts, Pharmacy Professionals, and Medical Directors. learn more »
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• Reference-Based Pricing: Our Reference-Based Pricing solution is a different, value-based approach to medical cost savings. Our coordinated and integrated medical management programs identify the most important cost providers. Our cross-functional teams include MAP® for physician profiling, pharmacy management, utilization management, case management and balance billing experts to ensure participants’ coordination of care and effective use of plan resources to address cost drivers. learn more »