TPA + PBM Case Study
How Northwind Improved Member Health Outcomes for a Taft-Hartley Client while also Reducing Pharmacy Spend by 13%
A self-funded Taft-Hartley health and welfare fund partnered with Northwind Health to manage pharmacy benefits for nearly 8,000 members — and the results speak for themselves: a 13% drop in net cost per member, $3.5M in rebates returned to the plan, and 64% of enrolled diabetes members now at goal A1c.
Program Results
The Numbers Tell the Story
A 13% reduction in net PMPM — even as prescription volume rose 17% and eligible membership grew 8% — reflects a plan that served more people and filled more prescriptions while paying less per member. That result is driven by tighter rebate capture, biosimilar substitution, and diabetes outcomes that reduce downstream specialty utilization. Among enrolled diabetes members, an average A1c decrease of 2.2 points among those starting above 8.0 is clinically meaningful: sustained reductions of that size are associated with materially lower rates of retinopathy, nephropathy, and cardiovascular complications in poorly controlled populations.
Net PMPM reduction, year over year (after rebates)
Rebates credited to the plan in 2025
Enrolled diabetes members now at goal A1c (≤7.0)
Average A1c point decrease among members starting above 8.0
Generic dispense rate
Of prescriptions filled with a member copay under $25
Savings from the biosimilar program
Health coaching engagement rate
Clinical Controls for Rising GLP-1 Spend
| Net PMPM (After Rebates) | Generic Dispense Rate | Rebates Returned to Plan | |
|---|---|---|---|
| 2024 (Prior Year) | $152.99 | 81.1% | — |
| 2025 (With Northwind Stewardship) | $133.29 | 82.7% | 21% of Plan Spend |
The Challenge
Fluctuating Eligibility.
Rising Specialty Spend.
No Margin for Error.
Trustees came into 2025 asking a direct question: was the Fund’s pharmacy spend actually buying better health for members, or just absorbing rising drug trend? Net PMPM had climbed to $152.99 the year before, GLP-1 demand was accelerating, and with no HR department to absorb a bad plan year, there was no room to guess.
Taft-Hartley funds carry a particular kind of pressure that most self-funded employer plans don’t: eligibility shifts monthly with hours worked, trustees answer to both employers and members, and a single high-cost specialty claim can ripple across an entire multiemployer population. Managing pharmacy benefit spend well isn’t optional here — it’s fiduciary.
Key Concerns
- Net PMPM of $152.99 in 2024 — a number trending in the wrong direction.
- Rising GLP-1 and specialty drug costs with limited built-in clinical oversight.
- A membership carrying significant chronic disease burden — type 2 diabetes and obesity, often together.
- Monthly eligibility swings (7,512 to 8,213 members over the year) that make cost forecasting difficult.
"Managing pharmacy benefit spend well isn't optional. It's fiduciary."
The Approach
Managed. Transparent. Clinically Accountable.
Northwind Health built a pharmacy stewardship program around the Fund’s membership that paired hands-on chronic disease management with disciplined rebate capture and benefit design — giving trustees a plan they could defend to both employers and members.
The program operated at the intersection of three disciplines most health plans treat as separate: Pharmacy Benefit Management, Chronic Disease Management, and transparent rebate pass-through. Bringing all three to bear on a single population isn’t just efficient — it’s how a 13% net cost reduction happens without members feeling it.
The program was built around two goals:
- Lower net cost on an honest, rebate-adjusted basis — not a number that only looks good before rebates are counted.
- Produce measurable clinical outcomes for the members driving the highest cost, primarily those with diabetes and obesity.
How It Works
- Every enrolled Diabetes Blueprint member receives dedicated health coach and pharmacist support.
- Prior authorizations for GLP-1s and specialty drugs are completed with clinical review — not rubber-stamped.
- Rebates are pursued and credited transparently, with GLP-1s and specialty agents driving the largest returns.
- Biosimilar substitution and enhanced "lesser of" pricing logic capture savings on every eligible fill.
- Members with diabetes crossover receive integrated chronic disease management alongside pharmacy benefit oversight.
RX STEWARDSHIP
Protecting the Fund Without Restricting Care
Northwind’s approach to pharmacy benefit management is designed to protect members who need high-cost therapies — and protect the Fund from spend that doesn’t meet clinical or pricing criteria.
Prior authorizations completed for high-cost and specialty medications.
PAs approved after clinical review (64% approval rate).
Members actively engaged in the Diabetes Clinical Blueprint®.
Rebates credited back to the plan in 2025.
THE BOTTOM LINE
Cost Control Without Clinical Oversight Is Just Cost-Shifting.
Pharmacy benefit costs are one of the most consequential line items a Taft-Hartley fund manages today. The question trustees face isn’t whether pharmacy trend will keep rising — it’s whether the plan is buying anything for it.
Northwind’s Strategic Rx Stewardship™ program gives trustees a defensible answer. Members get access to the medications and clinical support that improve their health. The Fund gets the rebate transparency and benefit design discipline that protect against unnecessary spend — and the outcomes data to prove every dollar was worth it.
Cost control isn’t cost-shifting. It’s stewardship.
