Case Studies

The success stories briefly summarized here represent just a few of the ways Capital Benefits has helped our clients achieve savings.

Selecting Pools

In New York State HMO's are required to use Community Rating to develop premiums. However, different community rating pools may be established according to the plan of benefits being offered. For example, a plan with a $15 co-pay could be a separate rating pool from a plan with a $25 co-pay. This situation can present opportunities for savings beyond simply the benefit differential.

One educational sector client had a $15 co-pay plan that was required by collective bargaining agreements. We advised them to consider a $25 co-pay plan and directly reimburse members for the difference. The premium savings were over 8 percent. Net savings to the client after reimbursement were nearly $500,000 annually.

Plan Design

A municipal client that was self insured for prescription benefits with a Pharmacy Benefit Manager established a goal of reducing costs via plan changes during upcoming collective bargaining talks.

We researched and quantified the various benefit changes necessary to achieve the objective, focusing on those that were least disruptive to members. These included a 3 Tier Formulary; Step Therapy; Over the Counter Therapeutic Interchange; Specialty Pharmacy Management; Limited Quantity edits; and Starter Doses.

Educational materials were prepared and distributed to the bargaining team and we presented the concepts at several bargaining sessions. The changes were ultimately accepted, resulting in first year net savings of 24 percent.

Carrier Audits

A cooperative of school districts was self insured with a large insurance company acting as their third party claims administrator. We worked with an in house team to establish an audit process that resulted in the recovery of nearly $5 million in overpayments.


NYRx is a Municipal Cooperative that was created by three of our clients (a city, county and community college) to jointly purchase Pharmacy Benefit Management (PBM) services for their individual self funded prescription benefit plans.

Capital Benefits worked with Arxcel, Inc. to develop a Request for Proposal, review bids and select the PBM. We then developed the Municipal Cooperative Agreement that was adopted by the three parties. It establishes a governance and administrative framework for managing the program. First year results showed a 15 percent savings compared to trend.

The NYRx program was recently awarded a $300,000 Shared Municipal Services Incentive grant from New York State to promote and market the plan to other municipal employers.