Operational resources for partners and clients
Everything you need to launch OptiMed, communicate with members, manage eligibility and claims, and track outcomes — organized by your role.
Getting started in 3 steps
Follow this sequence to get your team and members up and running with OptiMed efficiently.
Educate your team
Review OptiMed's program overview, FAQs, and the member onboarding guide so your HR and benefits team can answer member questions confidently.
Share resources
Distribute enrollment communications to eligible employees using the ready-to-send email templates. Direct them to complete their member profile setup.
Launch enrollment
Members complete the profile setup form and Patient Authorization Form. Track profile completion and outreach status with the OptiMed Client Liaison Team.
Member communication toolkit
Ready-to-use communication assets for partners and clients to share with eligible members.
Email templates
Three ready-to-send employer-to-member email templates. Customize with your group name and contact details.
Text message templates
Short, compliant SMS templates for member outreach.
Newsletter content
Pre-written newsletter copy in three lengths — drop directly into your internal communications.
Graphics & banners
Branded OptiMed digital assets for your intranet, email headers, and social channels.
Broker & consultant sales kit
Positioning, objection handling, and renewal materials for brokers and consultants presenting OptiMed to employer groups.
Common objections
OptiMed's model is built around continuity, not fragmentation. We identify impacted members before go-live, prioritize those with imminent doses, and coordinate directly with the existing provider — the member doesn't change their prescriber or restart the PA process from scratch. See the "How OptiMed protects continuity of care" section on this page.
Specialty carveout savings often offset any rebate exposure — particularly when the medications involved are medical-benefit infused or injected therapies where PBM rebates are limited or absent. OptiMed can model the net financial impact for a specific group. Contact the Client Liaison Team to request a cost analysis.
OptiMed works with the member's existing provider. The member's prescribing relationship does not change. For existing therapies, OptiMed coordinates the transition, collects active PA documentation, and avoids interruptions to ongoing treatments.
Provider office packet
Materials designed to help provider offices understand OptiMed's role and respond quickly to coordination requests — reducing delays for shared members.
How OptiMed prevents member disruption
A common concern with specialty carveouts is fragmentation. OptiMed's model is designed specifically to prevent it — we identify, prioritize, and coordinate before go-live so members never notice the transition.
- Identifies impacted members before go-liveClaims and eligibility data is reviewed to flag members on active specialty therapies before the plan start date.
- Prioritizes members with imminent doses or refillsMembers with upcoming dose dates are moved to the urgent outreach queue and handled first.
- Coordinates with the existing providerOptiMed contacts the prescribing provider directly — the member's physician relationship does not change.
- Collects clinicals and prescription informationDiagnosis records, active prescriptions, and site-of-care details are gathered from the provider to enable continuity.
- Reviews coverage before therapy beginsBenefits, prior authorization requirements, and cost-sharing are confirmed before any therapy is scheduled or shipped.
- Escalates urgent medication or infusion needsUrgent cases — missed dose, PA expiring, unresponsive provider — are flagged and escalated same day.
- Tracks outreach, profile completion, and unresolved casesPartners receive reporting on member engagement, open items, and cases at risk of disruption.
Existing therapy transition checklist
For members already on active treatments at go-live, OptiMed captures:
- Current medication, dose, and frequency
- Next dose or refill date
- Current provider name and contact
- Current site of care (office, infusion center, home)
- Open prior authorization numbers and expiration dates
- Any urgent or escalated cases flagged by the provider
- Member preference for site of care
Direct contracting & carveout checklist
For TPAs, PBMs, carriers, and employers evaluating or implementing a specialty carveout with OptiMed. Each area needs to be confirmed before go-live.
Eligibility
- File format and required fields confirmed
- Transmission frequency and method agreed upon
- Go-live cutoff date established
- Dependent handling rules documented
- Retroactive eligibility process defined
Claims & billing
- Medical vs. pharmacy benefit scope confirmed
- PBM interaction documented (carveout scope, rebate impact)
- TPA/carrier EOB and accumulator coordination confirmed
- Deductible and out-of-pocket limit handling agreed upon
- Billing contact and AR inbox confirmed
Prior authorization
- PA ownership (OptiMed vs. existing PBM/TPA) defined
- Delegated PA scope documented
- Clinical documentation requirements listed
- PA escalation path established
- Open PA transfer process for existing members confirmed
Data exchange
- Secure file transfer method configured (SFTP / portal)
- Minimum necessary data fields documented
- Report cadence and format agreed upon
- BAA executed
- PHI workflow secured and access-controlled
Provider coordination
- Provider fax and contact scripts prepared
- Clinical records checklist shared with provider offices
- Referral workflow documented and communicated
- Provider outreach lead identified at OptiMed
Member communications
- Launch calendar finalized (60/30/14-day touchpoints)
- Email and SMS communications started
- Member materials distributed
- Member profile setup link shared
Existing therapy transition
- Current members on active specialty therapies identified
- Urgent/imminent dose cases flagged
- Provider coordination initiated for active cases
- Open prior authorizations transferred
Measurement
- Baseline metrics established (eligible population, current spend)
- Reporting dashboard access confirmed
- Savings and activation reporting cadence agreed
- NPS / satisfaction tracking method defined
Member enrollment resources
Downloadable assets to share with members directly. Keep these as handouts and attachments.
Complete Member Profile Setup Guide
Full booklet for new members. English and Spanish.
Member Drug List
Coverage and impacted medications vary by plan. Use the lookup or contact OptiMed to confirm a member's specific coverage.
Member Profile Setup & Patient Authorization Form
Two key actions every new member needs to complete to get their care started with OptiMed.
Complete your Member Profile Setup
HIPAA secure — takes less than 10 minutes. Members complete this form so OptiMed Health Parnters can begin the intake process and coordinate care.
Patient Authorization Form
This form tells a member's providers that they want OptiMed Health Partners to help coordinate their treatment.
Step 1: Download
Step 2: Complete & sign
Step 3: Email to TreatmentNavigation@optimedhp.com
What happens next
Implementation process
A structured approach to delivering results through key milestones — from kickoff through ongoing account management.
- Align on goals & timeline
- Confirm implementation plan
- Review claims & plan data
- Identify key opportunities
- Launch member communications
- Begin member profile setup
- Monitor early engagement
- Track adherence
- Launch program
- Members begin care
- Track activity & outcomes
- Move to account management
- Provide ongoing support
What you can track
Designated partners and clients receive a quarterly report showing program performance. Below is an illustrative snapshot of the metrics included.
Sample data only. Actual metrics vary by group size, benefit design, and program maturity.
Member contact & referral tools
Refer a member
Submit a member for direct outreach from the OptiMed Team.
Secure member list upload
Submit an eligibility or outreach list for a coordinated outreach campaign. Files must not contain unnecessary PHI. BAA required.
Referral forms
Submit a provider referral or prior authorization request directly to OptiMed to initiate care coordination.
Response Times & Escalation Paths
Use this table to route issues to the right team and know what to expect. Member care disruptions are always prioritized.
| Scenario | Contact | Expected response | Escalation |
|---|---|---|---|
| Member's next dose or refill is due soon | Treatment Navigation 1-877-884-0998 |
Same day / urgent queue | Clinical escalation lead |
| Provider has not sent clinicals or prescription records | Treatment Navigation 1-877-884-0998 |
1 business day | Provider outreach lead |
| Employer has a launch, materials, or program question | Client Liaison Team clientliaison@optimedhp.com |
24 hours | Account manager |
| TPA or PBM data file issue (eligibility, claims, SFTP) | Implementation Team klassitter@optimedhp.com |
1 business day | Technical / data lead |
| Prior authorization question or handoff issue | Treatment Navigation 1-877-884-0998 |
1 business day | PA escalation lead |
| Billing, claims, or accounting issue | AR / Accounting AR_accounting@optimedhp.com |
2 business days | Finance lead |
| Contracting, legal, or BAA question | Contracting Team contracting@optimedhp.com |
2 business days | Legal lead |
Frequently asked questions
The health plan may require OptiMed for certain specialty medications or services. If questions arise, the Treatment Navigation Team can walk through the member's specific options.
Members may enroll during eligible windows or as defined by the program agreement. Contact the Treatment Navigation Team for specifics.
OptiMed focuses on the medical benefit for infused and injected specialty therapies — the scope that typically sits outside the PBM's pharmacy benefit. PBM contract effects, rebate impacts, and fees should be evaluated with OptiMed's Implementation Team before go-live.
No. OptiMed coordinates with the member's existing provider. The prescribing relationship does not change.
Cost structures vary based on partner arrangements and program scope. Contact the Client Liaison Team or Implementation Team for a cost analysis specific to your group.
Before therapy begins, OptiMed reviews the member's coverage and explains cost-sharing expectations. No surprises before treatment starts.
OptiMed complies with HIPAA privacy standards and only shares information with those directly involved in the member's care. A BAA must be in place before any PHI is exchanged. Review the full Notice of Privacy Practices.
Members and providers contact the Treatment Navigation Team at 877.884.0998 or TreatmentNavigation@optimedhp.com. This line is reserved for members and providers only.
Who to Contact
Use this guide to reach the right team.
For the full directory, download the Client Contacts Guide.
Office hours: Monday–Friday, 9 AM – 6 PM EST
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