Cash in on savings on prescriptions

Consultants look at drug costs to find savings

ClaimLinx analyzes each company’s drug usage to find cost-cutting measures. First, it saves employers money. Most importantly, it helps workers be able to afford the medications they need consistently.

Why ClaimLinx Focuses on Rx Costs

Medications are one of the most important tools people have to maintain their health. However, prescription drug costs keep rising each year. By the end of last year, more than 20 generic drugs had a price increase of 29.4%. Also last year, the cost of more than 1,200 drugs rose by 5-6%. It’s a trend that has so far continued into 2021.

What research has shown is that when medication are expensive, people do not fill the prescription or do not do so consistently. In fact, between 20-30% of prescriptions are never filled because of costs. Up to 50% of medications for chronic illnesses are not taken consistently because they’re too expensive. That all adds up to a real impact on members’ health.

That’s why ClaimLinx prioritizes savings on prescriptions. We know it’s important for employees to take their medications consistently to be productive at work. We also know employers don’t have endless funds for drug coverage. To help with that, we focus on finding a balance between the two.

How ClamLinx Saves on Prescriptions

Our consultants get real-time data on prescription usage through our partner pharmacy benefit managers (PBM). Unlike with a standard insurance plan, ClaimLinx sets up a prescription drug plan with a PBM we trust. That allows our consultants to see which medications workers need and how much they cost. From there, our service team has many methods they can use to cut costs on prescriptions. That saves money for both the employer and the employee.

Enrolling in drug coupon programs

One of the ways ClaimLinx cuts costs on prescriptions is by researching drug programs and coupons for medications. These are many coupon programs through the manufacturers and through different pharmacies. There are also cost sharing programs available for those with financial need. We seek these out because they help the employer. But more importantly, they help the employee afford the drugs they need to stay healthy.

Moving members to a new plan

Another cost-saving measure is to move certain members on the plan to new health insurance plans with more prescription coverage or discounts. For some members, it makes more sense for them to be on a more comprehensive plan. The plan may be higher cost, but it will save in the long run if the drugs are expensive. Our agents are seasoned in taking this into account when finding members the plan that’s going to work best.

Finding generic version of drugs

As a part of ClaimLinx’s overall solution, we place an emphasis on educating members on costs so they can be good healthcare consumers. To help with that, we recommend members have an open dialogue with their providers about their prescriptions. We tell members to ask their doctors if they have chosen a brand name drug why that is. Is there an alternative that can achieve the same results. We also help workers research generic versions of brand name drugs, if they are available. Sometimes providers are unaware of the costs of prescriptions so it’s important to talk with them when the drugs are expensive.

Shows Schedule of Benefits at work

ClaimLinx customizes every client’s Schedule of Benefits

Every ClaimLinx client receives a custom schedule of benefits. ClaimLinx experts design it to fit the company’s needs, usage and budget. That is flexibility in plan design you can’t find anywhere else.

What is a Schedule of Benefits (SOB)

A Schedule of Benefits, or SOB, is a list of the services a health plan covers. It’s a record of the fees a member will be charged for certain standard services. Members receive an SOB at the beginning of their policy. It shows what treatments will be covered and at what dollar amount or percentage they will be covered. That way members know about how much the visit will cost before they arrive.

How ClaimLinx customizes SOBs

For any company that chooses the ClaimLinx Simple Option Solution, one of our expert consultants creates a custom SOB. For new clients, we typically base the first SOB on the company’s previous plan. That way there’s no disruption in coverage or benefits. It’s a seamless transition from a client’s old plan to the ClaimLinx Solution.

After the client has made the transition, our consultants look at usage throughout the year. That’s because ClamLinx is a third-party administrator. That means we process the claims in-house. This allows us to see how members are using the plan in real time. Using that information, our consultants can make adjustments to help the plan work better. With regular group insurance, employers never see how much their workers are using the plan. But with ClaimLinx, we’re able to tell you what services members are using. That way, we can tell you what changes to make to either cut costs or improve benefits.

Because the plan is not through a big insurance company, it does not have to fit a certain mold. We can change how much a member pays for specific services without having to change the entire plan. Also because this is all done in-house, it can be done quickly, even before renewal.  You will not find more flexibility in a health plan.

Why custom benefits are better

Being able to customize the health plan helps companies make sure budget and and benefit goals are in sync. Because our consultants can see actual plan usage, they can tell clients where they may be able to adjust the plan to lower costs. For example, we often see companies that have a lot of emergency room claims, which tend to be very expensive. In this scenario, we recommend raising the cost of those claims to the employee and lowering the cost of urgent care visits. That way, members are being taught and encouraged to find lower costs alternatives to going straight to the emergency room.

Custom benefits are also great because they can be adjusted to reflect your company’s specific needs and/or demographics. For example, a company with a lot of families may want to make sure the cost of office visits stays low to ensure children and parents can afford preventative care visits. Or, alternatively, a company with a lot of older employees may want to cover more testing procedures or prescription medications to help works afford to manage any chronic conditions they may have.

There is so much our consultants can do to make sure the health plan is working for everyone. It doesn’t have to break the bank. And at the end of the day, having healthy employees improves productivity for the company. That’s happy for everyone.



In case, you or anyone in your family has decided to get insurance then you need to fill out Form 1095-A. You must get them to initiate the complete procedure of getting insurance. Form 1095-A is available at your account for all users.


What is Form 1095-A comprised of

Your 1095-A provided information about Marketplace plans anyone in your family has had including:

  1. Any paid Premiums
  2. Utilized Premium Tax Credits
  3. Your SLCSP (Second-lowest-cost silver plan)

You’ll use information from your 1095-A to fill out Form 8962, Premium Tax credit. This is often how you’ll “reconcile” — determine if there’s any difference between the premium tax credit you used and therefore the amount you qualify for and if you didn’t take any advance payments for your premium tax credit despite having Marketplace coverage.



Important Facts to Remember:

  1. Form 1095-A shall provide information about your family’s marketplace plans in 2020.
  2. It is important to keep this Form readily available and store it where you keep your tax information and other details.
  3. Keep in mind that the IRS does not provide Form 1095-A, you can get it from the marketplace.


How to find your 1095-A online

Your 1095-A is available in your account

  1. Below “Your Existing Applications,” go to our 2020 application.
  2. Choose “Tax Forms” from the left-hand side menu
  3. Save all the 1095-A files

In case you couldn’t find 1095-A in your account, you can reach out to the service center for any inquiries.


What to do if your information on Form 1095-A is wrong

It is very important to carefully analyze information filled out on your Form 1095-A in order to rule out any discrepancies.

Read the instructions at the back end carefully and make sure the information is accurate. If anything about your coverage or household is wrong, contact the Marketplace call center.  Also, it is very important to make sure that your SLCSP information is mentioned correctly.


How to know if your SLCSP information is correct

You can easily check your SLCSP information by following these steps:

You’ll notice Column B in Part 3 titled “Monthly SLCSP”. This would include facts and figures for all of your family members and their marketplace plans.


You’ll know that the SLCSP premium information is wrong if:

  1. There is a blank portion in Column B, Part III, or if it has a “0” during the months where your family members had the marketplace plan.
  2. If there were significant changes that weren’t communicated to the marketplace, i.e. getting divorced or married, losing a family member or having a baby, etc.


Use the knowledge from your 1095-A to “reconcile”

Once you’ve got an accurate 1095-A and your SLCSP premium, you’re able to fill out Form 8962 easily and reconcile your premium tax credit.


What is a Medicare advantage plan and should I get it?

Medicare is a private insurance plan. However, advantage plans are an alternative to private insurance. These plans are distinct from Medicare and have several pros and cons. 

Medicare Advantage plans may vary and can provide better care, flexible plans, and saving opportunities. On the other hand, some plans may be too expensive to afford, have fewer options to offer, and may require changes in your lifestyle. 

We will provide information on Medicare advantages in this article and also their procedure, advantages, and disadvantages so you can know whether they are suitable for you or not.

What is Medicare Advantage?

Medicare Advantage is an extension of Medicare’s original plans and is often known as Medicare Part C. Several private insurance companies offer these plans. The features of these plans are a combination of original plans (Part A and Part B) and with some modification and additional options, Part C is made. 

Most Medicare Advantage plans offer the following benefits:

  •  Hospitalization
  •  Hearing
  •  Some home healthcare services
  •  Vision
  •  Prescription drug coverage
  •  Hospice care
  •  Dental
  •  Doctor’s visits
  •  Preventive care

Types of Medicare Advantage plans

There are a variety of Medicare advantage plans that you can choose from depending upon your needs: 

  • Health Maintenance Organization (HMO). By opting for HMO plans, you will be provided in-network doctors for your service. However, for the appointment of doctors, you may need referrals.
  • Preferred Provider Organization (PPO). As opposed to HMO, PPO plans offer both in-network and out-of-network medical services but the cost for both of them is different. 
  • Private Fee-for-Service (PFFS). PFFS plans offer flexibility in terms of payment and can be designed depending upon your capability.
  • Special Needs Plans (SNPs). SNPs are designed for payment for chronic medical conditions and long-term. 
  • Medical Savings Account (MSA). MSA plans are opted in pair with costly health plans and help to save money from medical expenditures. 

Medicare Advantage Benefits 

Medicare advantage plans benefits and options are more than that of original Medicare plans. 

Convenient coverage options

Original Medicare plans offer limited coverage and options and you need to purchase other plans to cover additional expenditures. If you opt for Original Medicare, it will only provide hospital insurance and medical insurance. If your needs are not covered in these two coverage options, you will need Medicare Part D for covering the cost of prescription drugs and Medigap for supplemental coverage.

Contrary to Medicare plans, all your needs and additional coverage are covered in the Medicare Advantage plans.

Personalized plan structures

Medicare Advantage provides flexible plans for every distinct situation and needs. For example, as mentioned before HMO plans can offer in-network specialists and if you don’t prefer them you can opt for PPO plans and get your desired services. Similarly, the PFFS plan can also provide consumer freedom and lets you select your options freely. Apart from basic medical services, these plans also provide additional services like hearing, dental and preventive care, etc. 

Cost-saving opportunities

Most of the Advantage plans are quite affordable and offer little to no deductible cost and cover best services without purchasing premiums. If you can’t cover all your costs in these plans, you’ll have to pay out-of-pocket but Medicare Advantage plans set annual limits of such costs. Also, you can save more by opting Medicare Advantage plan in services like laboratory expenses and medical equipment. You’ll be able to see much more savings if you end up choosing a Medicare HMO plan. 

Coordinated medical care

Many Medicare Advantage plans have a coordinated care network. Your healthcare providers are constantly communicating to get you the best care possible through various healthcare services. The service provider does all the interactions for you and you can save the expenses of choosing a healthcare team and you can have a group of specialists ready at your disposal. According to researchers, this type of medical care results in better service for the patients which has been estimated by higher ratings and it also eases the work of medical staff and can avoid any unpleasant experiences.

Disadvantages of Medicare Advantage

With all the mentioned advantages of the Medicare Advantage plans, most of the people are quite content by choosing them. However, these plans also have some disadvantages which may trouble you. 

Limited service providers

If you opt for a Medicare Advantage plan instead of the original Medicare plans you may be limited to the health care providers. Such as HMO, it limits you to choose from only in-network specialists and you need to pay additionally if you plan to choose otherwise i.e out-of-network. Similarly, the plans, which do not pose such restrictions, are expensive and have high deductibles and copays. 

Complex plan offerings

Medicare provides a tool, find a plan, through which you can narrow down your search for plans. You’ll see that many Medicare Advantage plans limits their options in different ZIP codes. Some users might find it difficult not be able to access certain benefits due to different ZIP codes. 

Additional costs for coverage

Original Medicare plan only provides two coverage option and also have a high deductible, copays, and premium plans. In addition to this, you may need to pay for any Part D or Medigap for additional coverage.

Medicare Advantage plans provide a variety of options without these additional plans but their cost is more than Original Medicare plans. For example, many Medicare Advantage plans include drug deductibles and specialist visit copays.

State-specific coverage

Original Medicare’s services spread all across the United States. On the other hand, Medicare Advantage plans extend their special services in selected areas. So, if you are currently utilizing the Medicare Advantage plan, and you change your residence, your current plan may not be functional anymore.

The takeaway

As mentioned above, Medicare Advantage has many advantages over the Original Medicare plan such as better care, flexible plans, and saving opportunities. But these plans pose more restrictions, limit services and are more costly.



Maximize Your Health Insurance in 2021

The circumstances of 2020, caught every off guard. It was a continuous task of catching up with the new research studies and following preventive measures. With the circumstances getting worse, a lot more issues evolved, and with adapting to a new lifestyle, health care was primarily neglected by most of us.

Luckily with initial doses of vaccines being out in the market, there does seem to be a newfound hope of going back to our previous way of life. 2021 has begun with new hopes of better days coming. With these extraordinary times going by it’s time that you start focusing again on your and your family’s health care. Starting from setting healthier habits to maximizing your health insurance benefits to be prepared for any unforeseen health challenges.

Health insurances if planed correctly can easily become your best asset during difficult times. They can make your money work harder for you so you can get paid off your hard work when. there are difficult times ahead of you.

Have a look at the six of to top tips to maximize your health insurance in 2021

1. Consider choosing a plan that includes an HSA or FSA

Based on your family needs, you must work opening a health financial account like HSA or FSA. It is one of the best ways to make your money work harder for you. These both are saving accounts that one can utilize for out-of-pocket medical expenses and health care needs. For example life-saving drugs and eyesight care.

Before you decide on choosing any one of these. You must understand who these both are different from one another and how they would offer to you. For instance, In the case of HSA accounts, you have possession of the account. You have the freedom to utilize the funds. You can use them if you have recently switched from one job to another. You can invest in mutual funds, bonds, or stocks according to your choice. You can even save it up to your retirement time

On the other FSA have more restrictions. Because they’re owned by your employer, you can’t take an FSA with you if you leave, and any leftover money gets forfeited at the end of your insurance year.

If you go for HSA, you should consider your doctor visits and keep a check on how many times you visit them. You can only avail HSAs if have chosen a federally qualified high-deductible health plan. These plans have higher limits for out-of-pocket expenditures. Some employers that offer a health plan with an HSA will partially fund the account on behalf of their employees to help offset these out-of-pocket costs throughout the plan year. You can contact your employer to check the possibilities he offers. 


2. Understand your employer’s benefits before taking the job

We change our jobs very often due to upgrades and nicer salary. However, when looking for jobs we consider every other feature except the health plans they offer. Insurances are an important part of our life and if the provided plan does not fulfill our needs, out-of-pocket costs may use all your savings and leave you with nothing. It is important to pay attention to the health packages while choosing a job and you need to discuss this with your employer before making a final decision. 

3. Plan for any elective procedures you or your family will need

The pandemic since the last year has made things difficult for everyone and has also brought changes in the health plans as they are most needed now more than ever. Some new elective procedures have also emerged as things have started to settle. It is hard to select the perfect health care for you and your family and you never know when you will come across additional medical expenditures. You should research about different plans which cover all your costs and additional expenses and choose the most suitable one. The members of Harvard Pilgrim have a service tool called Estimate My Cost to estimate the cost of your plan in your area. Also, Reduce My Costs helps the members to save money by searching for inexpensive medical services and diagnostic facilities. 

Expenses increase considerably when you are a parent or are expecting a child. Parents now need to save more to give their child a brighter future and if you are already a parent of grown children, the responsibility is now double due to increased expenditures with age. There are some things you need to consider before choosing a family health insurance:

Make time for mental health

In troubled times like now, it is important to take care of your mental health and maintain your high spirits. Always check on your family and friends. Consider the mental health services and benefits your plan might include. As a member of Harvard Pilgrim, you have round-the-clock customer service, professional behavioral health treatment options (both in-person and virtually), online service, and programs for the care of their customers. Sanvello is also a tool available to keep your daily mood in check, therapists, support centers, coping tools, and guided journeys. 

Bottom line

The above-mentioned tips can be used to design and choose a perfect health plan for you and your family. There are several counselors to guide you to make the right choice. Also, every company has customer service that is always available, and also apps are also available for these purposes. 

Hopefully, these tips will help you make the best decision for you and your family in regards to health care. Follow these tips to maximize your health benefits. Maximizing the health benefits is essential for yourself and your family‘s longterm security. It will help you stay secures during the hard times and gives you the protection that you want to avoid unwanted circumstances. So plan well for your future and maximize your health insurance according to your requirements and budget.