Hooked on Rx
Only after a special contract-specific NDA signed by both consultant and member, and only for the selected PBM - not multiple contracts for comparison leverage.
Can we give out PBM Contracts?
A company or individual with enough resources and sophistication to understand and bear investment risk; for companies, the document references $5 million in assets or accredited individual owners.
What is an accredited investor?
Five elected members and two Pareto-appointed members, with terms staggered so only two or three seats typically turn over in a year.
How is the Board of Directors structured and elected?
A partner-success program built around recognition tiers, broker-of-record and prospect protections, retention and growth overrides, the Momentum Program, and exclusive perks/events.
What is the Consultant First Program?
Owns the plan and has primary responsibility for claims payment in self insured
Who is the Employer?
PBMs earn through admin fees rather than spread pricing, while Pareto collects small disclosed channel-management fees to support program management and clinical pharmacy infrastructure.
What are PRxC pass-through contracts and Pareto's PRxC revenue model?
We do not want to set up a first year member with a bad first year renewal with a need to load to change the contract terms.
Why don't we give discounts for short contracts?
A stop-loss cash-flow feature where, once a high-dollar claimant meets or is expected to exceed the specific deductible, the carrier pre-funds or reimburses amounts above that deductible so the employer does not have to front the full claim first.
What is specific advance? - Need to comment it is TPA dependent to be correct
The model in which one million metro residents roughly implies 1,000 mid-market businesses, and Pareto targets about 1% of those as annual new business.
What is the Pareto distribution model?
Who has responsibility for processing claims, eligibility and providing a network?
Who is the TPA?
An independent, conflict-free PBM consulting firm that helps large employers and health plans optimize pharmacy benefits and lower drug costs through PBM contracting, benefit design innovation, strategic analytics, clinical performance support, and audits.
Who is HealthStrategy?
By submitting the prospect’s name in writing to their RVP by 3/31/26, securing protection through 9/30/26 unless another consultant has already submitted that prospect for an indication or quote.
How does our broker prospect protection work?
A deductible that applies only to dollars above the specific deductible and may be satisfied by one individual or multiple individuals before normal specific reimbursement resumes.
What is an aggregating specific deductible?
The effect of first-dollar medical inflation in which the employer's deductible stays the same while the carrier's above-deductible exposure rises.
What is leveraged trend?
Employers often purchase this type of insurance to protect against catastrophic claims in a self-funded plan.
What is Stop Loss Insurance?
Manages drug spend by using a transparent, pass-through PBM model plus its specific programs to steer members toward the lowest-net-cost clinically appropriate options—especially biosimilars and partner specialty pharmacies—while passing savings through to clients.
How does Pareto manage specialty drug programs?
Not engaged in cost containment, Not attending member meetings, Multiple years of very bad claims, failure to pay stop loss premium or failure to pay needed capital.
How could a member be kicked out of the captive?
Fifty percent participation and 50 enrolled subscribers, with limited exceptions for 40-49 subscribers and avoidance of the core captive product for 25-40.
What are the minimum participation and subscriber requirements for new business?
New business usually renews on the same contract basis it entered with, but a 12/12 group is typically recommended to move to 24/12 with about a 20% factor load.
How does contract type change at the first-year renewal?
A major advantage of self-funded plans is reducing this kind of state-mandated tax or premium fee.
What are state premium taxes?
UMR has regional restrictions or thresholds on Rx carve-outs, and CVS/Caremark through Meritain is now available to any member regardless of TPA.
What are notable PRxC or ICM partner limitations and updates?
Because joining the captive is an equity investment, and Pareto wants owners/investors financially capable of understanding and protecting that investment.
Why does a member need to be an accredited investor?
The fully insured threshold below which the employer is credible and above which claims are pooled, with the carrier controlling the level and no cap on the pooling-charge increase.
What is a fully insured pooling point?
Admin worksheet and W-9, signed application/BAA, first month's premium, and a fully executed plan document before reimbursement requests can proceed.
What does HCC need for the full policy and claims reimbursement?
Unlike fully insured plans, self-funded plans are regulated primarily under this federal law.
What is ERISA? Not IRISA Mitch....