A consultant and benefits administrator reported to the board that Jefferson County’s self-funded health plan has run hotter than typical this year, hitting the aggregate stop-loss corridor at a level exposure staff described as above target. The county’s stop-loss reimbursements were described as having paid for certain large aggregated claims, but the aggregate metric used to set the stop-loss calculations has risen compared with historical benchmarks.

HR and benefits staff said the plan’s "specific" stop-loss performance was within acceptable range, but that the aggregate (which measures cumulative high-dollar claims across the group) has required an aggregate reimbursement in the current year. Staff provided preliminary notes that carriers and pharmacy benefit managers are changing business models (driven in part by new state rules on drug-rebate passthroughs), which may alter the way prescription costs are reflected in renewal proposals.

Benefits staff also highlighted specialty and GLP-1 prescription drugs (for example, Ozempic/Manjaro) as a significant and growing component of pharmacy cost. They described programs that can reduce specialty-drug costs — such as compound-pharmacy sourcing, manufacturer assistance programs and alternative procurement routes — and proposed educating employees about alternatives where clinically appropriate. Staff said they would wait for formal renewal numbers from the plan carrier before bringing a recommendation on whether to solicit competitive bids or change the Rx approach.

Why it matters: higher aggregate claims affect county budget planning and could require higher contributions or draw from reserves. Commissioners asked staff to wait for the carrier’s renewal numbers, then consider whether to request bids or adopt targeted pharmacy strategies.