Stability, integration, and predictability matter. A durable strategy connects pharmacy and medical claims, clinical review, sourcing, and stop-loss planning. 

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

Over the past few weeks, brokers, TPAs, and plan sponsors have asked me the same question: will the strategy we rely on today still be there next year? 

That is a fair question. When savings depend on one contract or channel, a change can put expected savings and member continuity at risk. A durable strategy connects pharmacy and medical claims, clinical review, sourcing, infusion setting, and stop-loss support. 

Why Stability Matters 

High-cost specialty drugs and infusions can drive significant plan spend. The risk is not only what a claim costs today. If a sourcing path or contract changes, members may face delays or cost changes, and the plan may need to revisit its savings and renewal assumptions. 

Carriers and actuaries need clear assumptions they can review. If savings cannot be measured, documented, and explained, they are hard to rely on when planning for renewal. 

How to Build a More Durable Strategy 

Avoiding variability does not mean giving up savings. It means building a foundation that can be measured and reviewed. 

Use more than one path. Review clinical needs, claims data, sourcing options, and the infusion setting. Choose the approach that fits the medication and the member. 

Put the terms in writing. Agree on what counts as savings, which costs and fees are included, and how results will be measured and validated. 

Ask the hard question. If market conditions change, what happens to the member, the claim, and the expected savings? 

Five Steps to a Long-Term High-Cost Rx Strategy 

1. Review the whole plan. Look at pharmacy claims, medical drug claims, and PBM terms together. Separate reviews can miss overlap and leave gaps. 

2. Manage medical and pharmacy together. Include infusion and J-code claims. When clinically appropriate, compare the infusion setting and total cost before changing where care is delivered. The clinical decision comes first. 

3. Coordinate with stop-loss early. Share the strategy before renewal and ask how the carrier will consider it in underwriting. Do not assume a program will lower rates. Put the assumptions and measures in writing. 

4. Use the agreement that fits the claim. A single-case agreement addresses a specific claim; an enterprise agreement sets terms across a plan. Choose the structure that fits the needs, document scope, pricing, and responsibilities. 

5. Build around validated results. Set the baseline, measurement period, and savings method up front. Give the plan, carrier, and actuary results they can review. 

What We Do at NIH 

National Integrative Health works alongside a plan’s existing PBM, TPA, and health plan. We review high-cost pharmacy and medical-benefit claims, including infusions, then look for the right path claim by claim. ¹ 

Depending on the medication, eligibility, and clinical fit, options may include direct manufacturer contracting, 340B sourcing, biosimilars or therapeutic alternatives, patient or manufacturer assistance, a different infusion setting, clinical trials, or a combination of pathways. Clinical review and coordination with members and treating providers come first. 

We coordinate with stop-loss carriers so they can evaluate the approach in underwriting. Savings are measured against actual plan-paid cost, net of fees and rebates.  There are no implementation fees, per-employee-per-month (PEPM) fees, or per-member-per-month (PMPM) charges. Fees are cost-plus and fully transparent, invoiced only after savings are delivered.  ² 

One 550-Life Group, 12 Months In 

A 550-life group came to NIH through a TPA partner that had previously been covered only through a BUCA carrier. Prior to the effective date, NIH worked with the stop-loss carrier to reduce the group’s premium by 10% because NIH’s program savings were actuarially validated up-front. After 12 months, reported drug cost moved from $120 to $85 per member per month, a 29% decrease. The $85 PMPM included all NIH fees. ³ 

These results reflect one group’s plan and contract terms. They are not a guarantee of results for another plan. 

Where to Start 

Start with real claims data. A repricing analysis can show where lower-cost options may be available and how potential savings can be measured. Reach out to see if your plan qualifies for a free Repricing Analysis. 

Request a Repricing Analysis 

About NIH 

National Integrative Health works alongside health plans, TPAs, and PBMs to manage high-cost pharmacy and infusion claims through data review, clinical coordination, sourcing, infusion care, stop-loss support, and clinical trials. Learn more at NationalIntegrativeHealth.com. 

Footnotes 

1. Program description. NIH’s 2026 company brochure describes work across pharmacy and infusion claims, clinical review, sourcing, site-of-care evaluation, and actuarial/underwriting support. This is NIH marketing collateral, not independent validation. NIH – Company Brochure 2026 

2. Fee model. NIH’s 2026 overview states there are no implementation fees or PEPM/PMPM charges, and that payment is tied to delivered savings. Confirm the exact contractual wording for the engagement being described. NIH – Quick Overview 2026 

3. The group had only been with a BUCA before NIH, the carrier reduced premium by 10% before launching because it could underwrite the program, and the $85 PMPM included NIH fees.