DeKalb County adopts negotiated health-plan changes after Apex annual review; pharmacy costs cited as main driver

DeKalb County commissioners heard an annual review of the county’s self‑funded health plan on Sept. 15 and were briefed on contract changes negotiated by benefits consultant Apex that the presenter said reduced the county’s projected fixed costs by roughly $323,000 and materially improved the county’s stop‑loss position.

Apex account executive Lauren (Apex senior account executive and principal) told commissioners the county moved administration and stop‑loss placement during renewal negotiations: administrative services were shifted from the prior vendor to PHP (a third‑party administrator) and stop‑loss coverage was placed with Companion Life, changes that Apex said produced the savings presented to the board.

Apex’s clinical manager Sage Muffin and director Andy May described plan‑year claims and clinical drivers. Apex reported that overall paid claims for the 07/01/2024–06/30/2025 plan year were approximately $4.0 million and that, after negotiating reinsurance and other items, the county ended the plan year with an $87,355 deficit against the budgeted maximum‑liability amount. The renewal negotiations reduced a proposed large carrier increase on maximum liability to a 5.8% increase (about $238,000) rather than the much larger increase originally proposed, and the reinsurance placement produced a reported net fixed‑cost savings (including administrative savings) that Apex quantified at roughly $323,000.

Why it matters: commissioners and county staff said they are most concerned about specialty pharmacy spending and the financial exposure of catastrophic claims. Apex said pharmacy spending — and specifically specialty drugs for musculoskeletal and immunologic conditions and newer GLP‑1 agents for diabetes/weight — accounted for a growing share of plan costs. Apex moved the county’s pharmacy contract from Optum to Prime Therapeutics with a “pass‑through” rebate arrangement intended to return negotiated rebates directly to the county rather than to the PBM.

Key details from the review

- Pharmacy and specialty drugs: Apex highlighted that specialty medications represented more than half of pharmacy spend for the year and named top drugs that hit the plan: Enbrel, a GLP‑1…