Overview
Clinical 360
Clinical 360+
The Sun Life Clinical 360 program combines our extensive high-cost claim data with clinical experts that act as a second set of eyes for our clients, reviewing claims to identify cost savings and care optimization opportunities. Clinical 360 is available at no additional cost to all Sun Life Stop-Loss clients. Watch the video below to hear more about Clinical 360.
Want to learn more? Contact your broker or Sun Life Stop-Loss Specialist
Clinical 360+ helps to simplify healthcare management for self-funded employers. Clinical 360+ builds upon Sun Life’s industry-leading Clinical 360 program, with the expertise of our clinical and care advisory teams and industry-leading partners to provide a curated suite of targeted health solutions to our self-funded clients.
Our approach includes: Optimizing medication costs and administration Supporting employees with serious illnesses Early intervention for health concerns Accessible musculoskeletal pain management Timely, appropriate care coordination Expert Cancer Review (ECR) written second opinion
Learn more
Sun Life is not responsible or liable for the care, services, or advice provided by Somatus, OptiMed Health Partners, or Hinge Health, and reserves the right to discontinue this service at any time. Sun Life will collaborate with your TPA on eligibility and applicability of programs. Health Navigator is provided by PinnacleCare. PinnacleCare is a member of the Sun Life Financial Inc. (“Sun Life”) family of companies. PinnacleCare and its employees do not diagnose medical conditions, recommend treatment options or provide medical care, and any information or services provided should not be considered medical advice. Any medical decisions should be made only after consultation with and at the direction of the member’s medical provider. Any person or entity who provides health care services following a referral or other service provided does so independently and not as an agent or representative of PinnacleCare. Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico. © 2024 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GSLCR-10937 #1475680447 08/24 (exp. 08/26)
We have enhanced our industry-leading Clinical 360 program by implanting new health capabilities. These programs offer our Stop-Loss clients and their employees with access to high value, comprehensive care in the comfort of their homes for conditions that typically result in some of the highest-cost claims.
Medical Rx 360
Kidney Care 360 and Heart Care 360
Sun Life has expanded its Clinical 360 program to include Kidney Care 360 and Heart Care 360 for self-funded employers. These solutions aim to improve health outcomes, reduce costs, and enhance care experiences for members with chronic kidney disease and heart conditions. The program focuses on slowing disease progression, boosting employee health and productivity, and managing care costs effectively. By working with the Clinical 360 team, employees can better manage their care, leading to improved health outcomes and optimized healthcare expenditures.
Sun Life is focused on developing high-impact solutions for self-funded employers to improve health outcomes and affordability of care. Medical Rx 360 enhances our industry-leading Clinical 360 program to help manage the rising costs of specialty injectable and infusion drugs and deliver a better care experience for members.
Learn more about Medical Rx 360
Learn more about Kidney Care 360 and Heart Care 360
*Source: Sun Life 2024 internal data
Optimizing care and costs
Data-driven opportunity identification based on analysis of extensive claims and clinical data.
Access to a wide variety of programs including medical Rx management, negotiation specialists, and condition-specific management.
Our experienced clinicians work closely with brokers, administrators, and partners, to identify opportunities to optimize care and reduce costs. Our team draws on their clinical knowledge to find savings opportunities, such as identifying billing errors, finding duplicate charges, or moving high-cost infusions to more affordable at-home administration for a better care experience. Our relationships with care providers and preferred partnerships allow us to negotiate out-of-network fees and access condition-specific management programs.
In 2024, Sun Life’s Clinical 360 program achieved over $47 million in savings.*
To learn more about Clinical 360, check out our library of success stories.
Clinical 360+ transforming care for everyday and complex health challenges
Musculoskeletal (MSK) care
Complex medication management
Heart and kidney disease care
Second opinions for cancer
Navigating complex conditions & prevention
To learn more, contact your broker or Sun Life Stop-Loss Specialist
Clinical 360+ offers personalized pathways for musculoskeletal, kidney & heart, and complex medication care. We combine expert navigation, digital tools, and condition-specific programs to support members with chronic pain, organ dysfunction, or complex drug therapies. We proactively reach out to employees, ensuring they know what's available and how to access it. By actively connecting your workforce to the care they need, we make their healthcare journey smoother and easier.
Clinical 360+ Program
Click below to learn about our targeted health capabilities for our clients:
Kidney Care 360 & Heart Care 360
Musculoskeletal Care
Sun Life Health Navigator
Sun Life Health 360
Member journey
Member success story
What does success mean for this solution?
ECR leverages the expertise of the Sun Life Health Navigator team, which has over 15 years of experience in coordinating expert medical opinions. Through this service, members receive dedicated support from a personal coordinator who manages the entire process. This comprehensive assistance includes collecting medical records, coordinating opinions from specialists, and offering ongoing question support throughout the member's journey.
Improved outcomes
Starting Point: Communication
Step 1: Outreach
Step 2: Enrollment
Step 3: Care Delivery
Final Step: Ongoing Support
Click on the footsteps to follow along the journey
Support from ECR Medical Directors for additional questions related to the written opinion or an additional written opinion from a different specialist.**
A timely expert written second opinion delivered to individual and treating physician
Medical records are collected by the ECR coordinator and provided to an oncology specialist for review and opinion
Member submits an online form and an ECR coordinator reaches out to collect additional information
Employer communicates with member about the voluntary ECR program
of written second opinions from qualified specialists led to a change in diagnostic strategy, diagnosis or treatment plan. *
At Sun Life, we believe that engaged employees are the key to a healthier, more productive workforce.
Empowered Health Management
Expert Cancer Review
39%
Originally recommended treatment: chemotherapy and radiation Recommendations provided in written opinion: Treat the cancer more locally through surgery and radiation, rather than chemo. Member Impact: Fewer side effects and better quality for life throughout treatment for the member Surgery is more costly than chemotherapy initially, but is a better long-term treatment for this member
Diagnosis: metastatic pancreatic cancer
Original recommended treatment plan: dose-dense AC-T chemotherapy Recommendations provided in written opinion: A less intensive chemo regimen of TC, better aligning with the less aggressive type of cancer. Member Impact: New treatment plan has a shorter duration and fewer side effects for the member while achieving a similar outcome TC chemo has an approximate savings of $25K from dose-dense AC-T chemo
Diagnosis: Stage III breast cancer
Originally recommended treatment: chemotherapy and immunotherapy Recommendations provided in written opinion: Only chemo. Studies did not show an added benefit to also receiving immunotherapy. Member Impact: Less intensive treatment plan for the member, while still achieving similar outcomes Reducing the risk of infection and other side effects from immunotherapy Eliminating the cost of immunotherapy – approximately $205K
Diagnosis: Stage IIIC1 uterine cancer
metastatic pancreatic cancer
Stage IIIC1 uterine cancer
Stage III breast cancer
All stories represent an actual Sun Life member’s experience and has been deidentified for privacy purposes. Cost savings based on Advanced Medical Strategies (AMS) estimates. * Sun Life 2023-2024 book of business.
Why ECR Engagement Matters:
Engaged ECR users tend to be more proactive about their health, leading to improved overall wellness.
Higher ECR utilization contributes to more effective healthcare management and potentially lower costs for your organization.
The convenience and efficiency of ECR can boost overall satisfaction with your benefits package.
ECR provides your employees with timely access to medical information, enabling them to make informed decisions about their health.
Increased Employee Satisfaction
Better Health Outcomes
Enhanced Plan Performance
Step 1:
Final Step:
*Excluding captive clients **Covered individuals can get up to two written second opinions at Sun Life’s expense. Additional reviews can be coordinated at a cost to the individual
Source: OptiMed Health Plan internal data from 2018-2023. Estimated savings are case specific and will vary with each patient and situation.
Full Carve Out (FCO) fosters an expected success rate of nearly 100%, offering cost savings and serving as a proactive solution. The member experience with FCO is generally positive—as it offers various site of care options (home and several outpatient sites of care), as well as a no cost share benefit. Additionally, transitioning to FCO typically reduces friction between members and providers, leading to smoother interactions and improved satisfaction overall.
Single case agreements have a success rate of 44%, contingent on buy-in from the provider, member, and client as well as the ability to procure the drug or change the site of care.
Member success stories
Applying Medical Rx 360 strategies to even just a small percentage of claims can reduce spend on certain high-cost drugs 15-55%, while also providing members with better access to care.
Delivering results
Starting Point: Identification
Clinical check-ins, therapy management, billing support
If opted in, OptiMed coordinates with current prescriber to transition care
Member decides to opt into the program or decline
OptiMed representative contacts the member via phone to explain program benefits
Identified via claims and clinical analysis by Sun Life. Employer communicates with member about the voluntary OptiMed program
Resources for you
A 50-year-old male with multiple chronic conditions, including high blood pressure, congestive heart failure (CHF), stage 3 chronic kidney disease (CKD), and diabetes, was experiencing frequent CHF-related hospital admissions before engaging with Somatus. The member struggled with poorly controlled blood pressure and needed support in managing his conditions. Somatus intervened by providing coaching on medication and diuretic adherence, offering symptom management plans for high blood pressure and CHF, and addressing concerns about medication affordability. Additionally, dietary counseling was provided to help reduce fluid intake and manage sodium consumption.
Full carve out
Single case agreement
OptiMed works with member to transition medication supply and coordinate with prescribers or new providers if necessary
Member is informed about the program and guided through the transition process
Member receives call or welcome packet from OptiMed
Member identified via claims analysis or employer notification
Check out some impactful success stories below:
Managing escalating infusion costs for a client
Reducing costs & improving the member experience
By redirecting infusions from the hospital to the members' homes, we reduce the risk of infection and complications while reducing costs an estimated $100,00 per year.
A change to at home treatments from a dedicated care team, gave a pediatric member and their family peace of mind that the life-changing infusions their child needs will continue to be covered and delivered with limited interruption to their daily lives, while reducing costs an estimated $396K per year.
Implementing Medical Rx 360
Learn more about:
Comprehensive program
Medical Rx 360 overview
Single-case agreements
** This is a voluntary program that the member or provider may decline
Through Kidney Care 360 and Heart Care 360, our partner Somatus offers specialized healthcare services focusing on supporting individuals with chronic kidney disease, congestive heart failure, and related conditions. Their proven care model aims to provide sufficient services and utilization of existing services to prevent disease progression and prevent costly medical events, like unnecessary hospitalizations. Working alongside Sun Life's Clinical 360 team, this service provides comprehensive support, including integrated care, coordination with existing care teams, and multidisciplinary expertise from nurse care managers, social workers, dietitians, and clinical pharmacists.
Click here to hear how this approach to care has impacted OptiMed patients.
Learn more about Kidney Care 360 and Heart 360
Information anonymized to protect patient confidentiality
Delivering better outcomes to our members
A 50-year-old male with a history of high blood pressure, congestive heart failure (CHF), stage 3 chronic kidney disease, and diabetes had multiple hospital admissions related to his CHF before working with Somatus. He connected with Somatus for help controlling his blood pressure and managing his symptoms and medications. Through working with a Somatus coach, he was able to better manage his condition by taking his medications and diuretics regularly. In addition, he was provided assistance with medication costs, education on managing his CHF and dietary counseling to reduce fluid and sodium intake. After implementing these health changes to his daily life, his blood pressure improved to normal levels, his weight decreased, and his risk level was reduced from high to low. Additionally, he had a 98% reduction in healthcare claim costs after working with Somatus.
1. Analysis of 11 months of member claims pre Somatus activation (January 2021-November 2021) compared to 12 months of member claims post Somatus engagement (December 2021-December 2022). Information anonymized to protect patient confidentiality.
To help your members get the most value from the newly added benefits, we recommend a broad marketing approach that raises awareness and drives engagement. At Sun Life and Somatus, we use highly targeted outreach strategies to ensure eligible members are aware of—and supported in using—these programs effectively.
Ongoing care team collaboration for comprehensive disease management
Nurse, registered dietician, and pharmacist coordinate care and appointments
Voluntary enrollment and assessment with care manager
Member receives outreach from Somatus or push notification
Identified via claims and clinical analysis by Sun Life
As a result of these interventions, the patient experienced a reduction in claim costs.1 His blood pressure returned to normal range, he lost weight, and his clinical stratification decreased from high to low risk.
Member 2
Member 1
His story demonstrates the significant impact of targeted interventions and personalized care in improving health outcomes and reducing healthcare costs for patients with complex chronic conditions.
Transforming health outcomes for multiple chronic conditions
A comprehensive care approach transforms the life of a member with advanced kidney disease
A 47-year-old female with Stage 4 CKD, hypertension, and Type 2 diabetes was facing multiple in-patient hospital stays and emergency department visits before her engagement with Somatus. The patient had poorly controlled blood pressure (183/96) and needed education and a symptom management plan. She was also interested in learning about a renal diet and was experiencing fatigue that affected her social life. Somatus provided education and support for managing her conditions, including blood pressure control and dietary guidance.
As a result of this intervention, the patient achieved a reduction in monthly medical expenses2 and experienced no in-patient hospitalizations or emergency department visits since engaging with Somatus. Her blood pressure became well-controlled through diet and medication adjustments. Furthermore, she was referred for a kidney transplant workup and began preparing for potential dialysis.
This case illustrates how comprehensive care management can significantly improve quality of life, reduce healthcare utilization, and prepare patients for future treatment options in advanced kidney disease.
2. Analysis of 9 months of claims of member pre Somatus activation compared to 8 months of claims of member post Somatus engagement 2022-2024. Information anonymized to protect patient confidentiality,
Your organization may not have eligible members for these services. However, should eligibility arise, our Sun Life clinical team is prepared to identify these members early and involve them in the appropriate services as quickly as possible. Having up-to-date demographic information is crucial in these situations, allowing us to reach the right member at the right time.
By working together to ensure your employee population is accurately represented in our eligibility data, we can maximize the effectiveness of member engagement in these programs. This collaborative approach helps us deliver targeted care to those who need it most, improving health outcomes and managing healthcare costs more efficiently.
Sun Life + Somatus
Getting Started with Somatus
Implementing Sun Life Clinical 360+
Overcoming chronic ankle pain
Starting Point: Member Self-Identification
Member engages in progress tracking, receives lifestyle coaching, and benefits from technology-guided care
Member receives a personalized exercise and education program tailored to their specific needs
Member completes a health screener and participates in a video consultation with a care provider
Member accesses the Hinge Health app to explore care options
Member experiences joint or muscle pain and recognizes the need for care
Sarah (member name has been changed), a woman in her early sixties, was battling chronic ankle pain that affected her daily activities. Before participating in the Hinge Health program, she found it challenging to walk, climb stairs, and had to cope with persistent pain every day. Her pain was rated as moderate to severe on a standard pain scale.
That’s when she was introduced to Hinge Health through the Clinical 360+ program. Sarah downloaded the Hinge Health app, completed a quick clinical screener, and was soon connected with a care team that understood her needs. Her personalized program included guided exercises, education modules, and real-time feedback using camera-assisted technology—all from the comfort of home.
After just 12 weeks, Sarah experienced significant improvements. Her pain level decreased, moving from the moderate-to-severe range to the mild pain category. Sarah continues to participate in her Hinge Health program, now focused on maintaining her progress and integrating small, sustainable changes into her everyday life.
Hinge Health is more than a digital tool—it’s a personalized path to better health, with tangible results.
Employee confusion - We've noticed an increase in inquiries from employees seeking clarification about vendor communications. Unrealized benefits - The full potential of the program, including reduced absenteeism, improved retention, and decreased high-cost claims, may not be fully realized by the employer without a more proactive approach. Engagement gap - Members may not experience the full value of the program without consistent client participation and proactive communication with your employee base.
We've observed that achieving our target 2-3% engagement rate has been challenging without active participation from our clients. While Sun Life continues to distribute direct-to-member email campaigns and Hinge provides marketing communications, the absence of supplementary outreach from Clients has led to some unintended consequences:
Hinge offers a comprehensive solution that goes beyond cost savings, addressing critical aspects of workforce management such as employee retention, recruitment, absenteeism, and presenteeism. Through Hinge, employers can provide their employees with a best-in-class, clinically validated Musculoskeletal solution.
Untapped Potential
Maximized Value
An engaged client actively promotes our marketing efforts, contributing to our target of 2-3% member participation. Proactively communicating with your employees about upcoming campaigns and regularly highlighting the no-cost benefits available to them strengthens the relationship between your workforce, Sun Life, and our partners. This collaborative approach not only boosts engagement significantly but also delivers measurable results for your organization, including:
Reduced absenteeism Improved employee retention Decreased high-cost claims
By fostering this partnership, you're investing in your employees' well-being while simultaneously improving your company's bottom line.
To maximize the program's effectiveness and reach our mutual goals, we strongly encourage a more active role in promoting and supporting these initiatives within your organization. By partnering more closely, we can address employee concerns, highlight the program's benefits, and work towards achieving our engagement targets together.
Sun Life + Hinge Health
Hinge Health Member Overview
Expert support and guidance
How it works
Delivering results for our members
Learn more about Health Navigator
Health Navigator is available at a competitive PEPM.
Why Health Navigator
Value Story
FAQs
Knowledgeable and skilled team to help members
20 MD, PhD, and specialized medical researchers, including dedicated Behavioral Health researchers
Health Navigator is comprised of a muti-disciplinary team of health experts who collaborate to support our members. Our team includes:
By providing Health Navigator at a competitive PEPM alongside your Stop-Loss coverage, you will receive two new cost-saving benefits: a 10% step down deductible ($25k max) and 3% ADF credit.
We help members with any health need including finding in-network primary care providers and specialists, facilitating and preparing for appointments, collecting medical records, obtaining expert second opinions from qualified providers, and more.
Health advocacy and care navigation
Medical intelligence
A better member experience and improved outcomes
Successful healthcare navigation Confidence in healthcare decisions Improved health outcomes, often leading to reduced costs
In-depth medical knowledge on a wide range of health conditions combined with deep expertise in nuances of the healthcare system.
High-touch, highly personalized engagement model delivered by experienced Care advisors.
Enhanced employee benefits - Ongoing valuable support for health and wellbeing, aiding in talent attraction and retention with 92% average member satisfaction.2
Watch how Health Navigator helped one member after her daughter suffered a traumatic eye injury. Then, read more of our member success stories to discover how Health Navigator can benefit your organization and employees.
1 2024 Health Navigator Book of Business data. 2 2024 Health Navigator rolling survey, collected from members after service utilization.
Improved health outcomes - 47% of second opinions facilitated by Health Navigator result in recommended changes to diagnosis or treatment.1
One third of appointments for members diagnosed with cancer were expedited and scheduled with more qualified cancer specialists than the members' current providers.
100 Care Advisors (MDs, NDs, RNs, BSNs, MSWs) 8 Medical Directors 75 Medical Advisory Board members
130+ relationships at top regional and national hospital systems
Learn more about Sun Life Health 360
About Sun Life Health 360
View a demo of Sun Life Health 360
Access to Sun Life Health 360 is provided at Sun Life’s expense.
Direct access to health capabilities: Health Navigator, Hinge Health, Kidney Care 360, and Heart Care 360
An expansive library providing members with physician-reviewed health and wellness information
Self-led mental health support and educational content
Fitness content, challenges, meditations and tracking capabilities to support a healthy lifestyle
Preventive health support to promote healthier living through wellness assessments and recommendations
