By Jake Velie, Founder, Chairman & CEO, National Integrative Health

Most people around a self-funded health plan already know pharmacy spend matters. What many still miss is where some of the biggest drug costs actually land.

They do not always show up in the PBM report. A meaningful share of high-cost drug exposure sits inside the medical claim, especially in infused and provider-administered therapies. That is where plans can lose control quickly, and where too many employers still rely on passive default pathways instead of active management.¹ ²

That is why infusion is drawing more attention.

This is not just a broker conversation. It is a plan sponsor conversation, a TPA conversation, a stop-loss conversation, and a PBM conversation too.

Rachel Strauss made the point clearly during our fireside chat: transparency is how you start to follow the money. She is right. Until a broker, plan sponsor, TPA, or carrier can see where a drug was billed, how it was sourced, and what site of care was used, they are not truly managing the claim. They are reacting to it after the cost is already in the plan.

The real issue is not only the drug, it is the pathway

Too many people still approach infusion spend as if the drug itself is the only variable that matters. It is not.

The economics are shaped by at least four factors: the therapy selected, the place of service, the reimbursement structure, and the discipline of the people managing the claim. When those variables go unmanaged, high-cost cases tend to flow to the most expensive channel.³ ⁴

That is why two plans can cover the same therapy for the same condition and still end up with very different financial outcomes.

Chris McLellan underscored an important point in the discussion: many of these opportunities first appear in the authorization process. That is where high-cost therapies can be identified, reviewed, and evaluated before they become fully embedded in the plan’s paid claims experience. That is also where a plan can determine whether a lower-cost but clinically appropriate pathway exists, whether a biosimilar should be considered, or whether the drug should be moved out of a hospital outpatient department and into a lower-cost setting.

That front-end work matters. Once a claim is paid through the wrong pathway, the plan is often left cleaning up a cost it could have prevented.

The same drug can create a very different claim

One of the clearest takeaways from the fireside chat was also one of the simplest: the same drug can cost dramatically different amounts depending on how it is sourced, where it is administered, and how the contract is structured.

We have seen that firsthand.

In one case discussed during the fireside chat, the plan reduced cost by roughly $80,000 per administration of Ultomiris after changing the procurement path and contracting structure while keeping treatment in the same physician-office setting. As I said during the panel, it was the same medicine, in the same chair, in the same building, just a different contract.⁶

That is the kind of issue brokers, plan sponsors, TPAs, stop-loss carriers, and PBMs should all be trained to spot.

When an infused claim is treated as fixed simply because the therapy is medically necessary, the plan often misses the larger question. The right question is not only whether the treatment should happen. The right question is whether it is being delivered through the lowest reasonable net-cost path.¹ ² ⁴

The Ultomiris case makes the point

This is where complex cases separate real operators from everyone else.

Ultomiris is a REMS drug. That means this is not just a pricing exercise or a basic site-of-care conversation. It requires a team that can work through sourcing rules, REMS requirements, provider coordination, plan authority, and the right administration pathway without losing control of the case.⁷

Many competitors do not handle cases like that. They may talk about infusion savings in the abstract, but they are not built to operationalize a REMS-governed case inside a live health plan.

That is why this particular case matters. It showcases NIH’s ability to handle any complex case in a health plan, not just the easy ones. If a team can navigate a case like Ultomiris correctly, it tells you something important about its ability to manage the rest of the book as well.

Why pre-cert and prior auth matter so much

If brokers, plan sponsors, TPAs, stop-loss carriers, and PBMs want to know where real leverage begins, it begins at pre-cert and prior auth.

That is the linchpin.

A claim can be routed toward the hospital outpatient department, or it can be redirected toward a more disciplined pathway. The difference often comes down to whether someone is evaluating the case early enough, with enough clinical detail and enough contractual flexibility, to intervene.

That is why data matters so much.

Self-funded plans with full-detail claims data can do far more than fully insured groups looking at high-level summary reporting. If the people managing the plan can see diagnosis codes, CPT detail, drug identifiers, and place-of-service patterns, they can start asking the right questions. Which infused therapies are driving the largest paid amounts? How much of that spend is happening in hospital outpatient departments? Which cases are clinically appropriate for redirection? What did the contract allow, and what did it prevent?³ ⁴ ⁵

Without that level of visibility, employers are not managing trend. They are absorbing it.

This is bigger than one claim

It is easy to look at infusion management as a one-off savings exercise. That is too narrow.

The value is not just in reducing the cost of one treatment. The value is in changing the trajectory of the plan.

When a high-cost infused claim is managed correctly, it can affect the immediate paid amount, the next renewal cycle, and the stop-loss conversation that follows. Those savings do not just show up once. They stack.

That is why plan sponsors, brokers, TPAs, stop-loss carriers, and PBMs should view this work as strategic, not tactical.

Rachel made another point worth holding onto: this is not as simple as shopping PBM to PBM. If the underlying plan documents and vendor contracts do not give the employer flexibility, the employer may know there is a better option and still be blocked from using it. That is not a drug problem. That is a contract problem.

Everyone around the plan needs to read those contracts like they matter, because they do.

Member experience still determines whether the strategy works

Savings alone are not enough. If a plan is going to redirect infusion care, the member experience has to be handled well.

That means the process must feel coordinated, supportive, and clear. It cannot feel like something is being taken away from the patient.

Chris spoke to that directly. In the strongest cases, the member is supported by case managers, clinicians, provider-office coordination, pharmacy coordination, and a clear treatment plan. When that happens, the experience becomes smoother, not harder.

That has been our view as well. When done right, a site-of-care change should not create chaos. It should create confidence.

What the market should do now

Brokers do not need to become infusion operators. Neither do plan sponsors, TPAs, stop-loss carriers, or PBMs. They do need to get sharper at spotting where infused drug spend is hiding and who, if anyone, is actually managing it.

That starts with a few direct questions:

• Where are the highest-cost infused claims landing today?
• How many are being billed through hospital outpatient departments?
• What authority exists at pre-cert and prior auth to redirect them?
• What does the SPD or vendor contract allow?
• Who is accountable for documenting why a high-cost claim followed the path it did?

Those are the questions that move the conversation forward.

Infusion spend is getting more attention for a reason. Employers are starting to realize that hospital-based drug administration is not just a clinical event. It is also a purchasing decision, a network decision, and a governance decision.

The organizations that understand that will walk into renewals with a stronger story, better questions, and more ways to protect plan dollars.

Footnotes

1. Internal NIH case notes describe a broker with more than 70 self-funded groups seeking an infusion carve-out for a 10/1 renewing group after review of claims including Keytruda and other J and Q codes.
2. NIH case notes describe a broker request for deeper analysis of site-of-care adjustments and Cyramza repricing.
3. PSG, 2026 Pharmacy Benefit Manager Customer Satisfaction Report. Internal notes summarizing 2025 specialty trend findings: gross specialty spend grew 10.8%, cost per claim was nearly flat at 0.1%, and utilization grew 10.6%.
4. Magellan Rx Management, Medical Pharmacy Trend Report: Site of Care Optimization. Research cited by Magellan indicates that shifting clinically appropriate infusions from hospital outpatient departments to lower-cost settings such as physician offices, ambulatory infusion centers, or home infusion can reduce administration costs by 40 to 60%.
5. U.S. Department of Labor, Employee Benefits Security Administration. Used here to support the employer-accountability and documentation framework for pharmacy-related spend oversight.
6. Fireside chat example describing a case in which approximately $80,000 per administration was removed by changing procurement and contracting structure while keeping treatment in the same physician-office setting.
7. NIH internal operating policy routes infusion drugs through a site-of-care feasibility workflow that reviews manufacturer labeling, FDA / REMS requirements, applicable clinical guidance, and the appropriate administration setting. REMS products are sourced domestically.