How It Works

Coverage Examples

RxPharmacy Assurance’s stop-loss supplement is designed specifically for pharmacy risk associated with conditions that have high-cost prescription therapies – and provides multi-year protection that extends beyond traditional stop-loss coverage.

Once an eligible member reaches a plan cost of $250,000, the plan is entitled to reimbursement of qualified expenses up to the limits of the policy—$1,000,000 annually; $3,000,000 lifetime. Employers that remain continuously enrolled will continue to receive benefits in subsequent years for those members that are new to plan or newly diagnosed after the initial enrollment date, up to the limits of the policy.

$250000

deductible

$1000000

annual limit

$3000000

lifetime limit

The stop-loss supplement enables employers to split drug claims between multiple parties. Once a client makes an insurance claim on a covered condition, financial responsibility is distributed amongst the following payers:

Client
Existing Stop-Loss Vendor
RxPharmacy Assurance

Here’s how it works

Let’s say a plan member is prescribed Myalept™, which treats leptin deficiencies in the body causing abnormal distribution of body fat and an insatiable appetite, an RxPharmacy Assurance covered condition.

$1.4 million

Drug Cost

$800000

Medical Claims:

$2.2 million

Stop-Loss Claim:

Plan with $125k Deductible

The plan sponsor is responsible for the first $125k in drug costs. After this amount is met, traditional stop-loss takes effect and the stop-loss vendor (SLV) is responsible for all drug expenses from $125k up to $250k. Together, the plan sponsor and the SLV will meet the $250k RxPharmacy Assurance supplemental stop-loss deductible.

RxPharmacy Assurance is responsible for the expenses from $250k, up to $1.25 million (and up to a lifetime max of $3 million). The remaining $150k from the claim is the responsibility of the plan sponsor or the SLV.

Plan with $250k Deductible

The plan sponsor is responsible for the first $250k in drug costs, which already meets RxPharmacy Assurance’s supplemental stop-loss deductible. With this deductible, the Stop-Loss Vendor (SLV) incurs no liability for the pharmacy claims and RxPharmacy Assurance is responsible for the expenses from $250k up to $1.25 million. The remaining $150k is the responsibility of either the plan sponsor or the SLV, depending on their policy.

$1000000

Potential savings

Traditional stop-loss insurance is not a complete solution to alleviating the risk of catastrophic claims. Stop-loss contracts have contract limitations for large claims, which can leave the employer exposed, or facing a massive rate increase.

The RxPharmacy Assurance solution can help brokers and plan sponsors negotiate improved stop-loss premiums and may protect member plans against future lasers, providing safeguards from unexpected and potentially catastrophic specialty drug claims.

To learn more, check out our FAQs page here.