High-Dollar Claims Layer
The 10% of claims that causes 85% of spend.
This is the severity layer: specialty drugs, hospital claims, pharmacy routing, out-of-network exposure, and the claims that decide the renewal.
We know you're going to have claims. It's not if you're going to have claims; how much you pay for those claims is the difference.
Benefit Schedule
| Benefit | Primary Handling | Deductible | Max Exposure | If Unavailable |
|---|---|---|---|---|
| Prescription Drugs | ||||
| Specialty Drugs |
MAP
International
340B
If not covered: 80/20
|
N/A | ACA Limit | 80/20 |
| Hospital Benefits Examples | ||||
| Regular Split | 80/20 | $0 | ACA Limit | No Limit |
The everyday copay layer makes the plan usable. This layer controls the damage: specialty drug sourcing, hospital pricing, and maximum exposure. Specialty drugs route through MAP, international, or 340B first; if not covered there, they fall back to 80/20.