May 12th, 2025
by Louis C. Bernardi, Certified Health Value Advisor | Certified Healthcare Fiduciary Coach | Benefit Optimization Officer | Founder | Health Rosetta Associate Advisor | Identical Twin | Podcast Host
Utilize Direct Contracting for Specialty Medications
One of the most effective strategies we’ve used to manage chronic conditions—and significantly reduce costs for both employers and employees—is direct contracting for high-cost injectable and specialty medications.
Traditional insurance models often funnel these medications through carrier-owned PBMs and preferred provider networks, where opaque pricing, inflated markups, and rebates hidden from plan sponsors result in exorbitant costs. This structure doesn’t just strain the plan—it also drives up members’ out-of-pocket expenses, sometimes forcing them to choose between affording their medication and other basic needs.
Direct contracting changes that. By partnering with transparent, independent vendors—whether it’s a specialty pharmacy, a direct-to-manufacturer sourcing partner, or even an infusion center—we’ve helped employers bypass the markup and take control. In one recent case, we coordinated a direct purchase of a specialty injectable that was originally billed at over $13,000 per dose. Through direct contracting, the plan acquired it for less than $2,000—a savings of over $11,000 per treatment. The member saved $9,000 in out-of-pocket costs and avoided unnecessary delays in care.
This strategy is especially powerful for conditions like rheumatoid arthritis, multiple sclerosis, and diabetes, where medications are essential and ongoing. It also improves adherence and outcomes by removing cost-related barriers and giving members access to trusted clinical support teams.
My advice to plan sponsors and HR leaders? Stop accepting the status quo. Just because your insurer says it’s the “best deal” doesn’t mean it is. Look under the hood. Ask for claims-level data. Understand the true cost of your medications—and then explore alternatives.
Direct contracting isn’t just a way to save money—it’s a way to do right by your people. And when you help employees manage chronic conditions affordably and effectively, everyone wins: employees get better care, the business lowers risk, and the health plan becomes a strategic advantage instead of a financial burden.
