How It Works
A repeatable process designed for low disruption.
The Process
From identification to ongoing management.
Identify High-Cost Claims
NIH analyzes claims data to surface high-cost medications, specialty therapies, and infusion treatments that may be driving plan spend. Each claim is reviewed in the context of the plan's broader profile and contractual arrangements.
Evaluate Clinical + Financial Pathways
For each flagged claim, NIH evaluates whether clinically appropriate alternatives exist, including lower net-cost direct contracts, site-of-care changes, or formulary adjustments that align with the plan's benefit design.
Source Lower Net-Cost Options
Where a viable pathway is identified, NIH sources and validates lower net-cost options through manufacturer programs, direct contracting, specialty pharmacy networks, and clinically appropriate therapeutic substitutions. NIH accesses over 7,000 drugs, including Limited Distribution, Rare Disease, and Orphan drugs.
Coordinate Member + Provider Outreach
NIH engages directly with members and their prescribing providers to explain available options, answer questions, and coordinate transitions...preserving continuity of care and member trust.
Prior Authorization + Execution
NIH provides or supports prior authorization workflows, documentation, and submission...working alongside the plan's existing PBM and clinical partners to ensure approvals and transitions proceed smoothly.
Report, Validate, and Continue Managing
NIH delivers regular reporting on opportunities identified, pathways activated, and savings validated. Ongoing case management continues to monitor every claim and surface new opportunities as pharmacy profiles evolve.
What makes the process work
This Only Works If You Execute
Days, not quarters
Repricing analysis returns in days, so plans can act mid-year without waiting on a renewal cycle to reduce exposure.
Claim-level precision
Every recommendation is tied to a specific high-cost claim with a documented lower net-cost pathway — not population averages.
One coordinated team
Clinical, pharmacy, and operations sit on one in-house team. Existing PBM, TPA, broker, and stop-loss relationships stay in place.
Validated savings
Outcomes are measured transparently against the original claim and reported back to the plan and stop-loss partner case by case.
Clinical
Clinical decision-making, in-house.
- In-house clinical team — not outsourced administration
- Therapeutic equivalence review and clinically appropriate alternatives
- Member and provider facilitation across pharmacy and medical benefit
- Prior authorization used as a clinical decision framework
- Site-of-care and infusion pathway coordination
Financial
Repricing, actuarial, and stop-loss.
- Claims-level repricing analysis across full pharmacy spend
- Actuarial analysis, underwriting support, and plan design consulting
- Stop-loss coordination designed to reduce specific exposure
- Case-by-case savings validation — paid only on delivered impact
- Ongoing reporting across the plan year
Ready to See the Process in Action?
Submit a Repricing Request.
Share a few details about your plan. NIH will scope a free Repricing Analysis designed to surface containment opportunities — without disrupting your existing benefit partnerships.