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 (Mounjaro/Munjaro), Humira and SKYRIZI. The county had multiple members on high‑cost specialty therapies; Apex noted 18 members receiving Mounjaro during the plan year.

- Stop‑loss and reinsurance: The team said the county negotiated a materially improved stop‑loss outcome versus an initial carrier proposal. Apex reported a 12.5% savings on reinsurance fixed costs from the re‑placement, and argued the county was able to avoid a much larger carrier increase on maximum liability.

- Administrative and ancillary changes: The county moved some ancillary coverages to Lincoln; dental moved from The Standard to Lincoln, producing employee savings on dental costs, and vision and voluntary benefits were being set up to follow open enrollment for voluntary lines.

- Organ transplant and other specialty coverage: Apex said the county added a fully insured organ transplant policy at about $33,000 per year so transplant claims would pay outside the self‑funded pool.

- Clinical and utilization observations: Apex’s clinical summary showed musculoskeletal surgery and spinal procedures, a few high‑cost cancer cases (three members with active cancer care, mostly breast cancer), and high utilization categories that reflected both medical and pharmacy drivers. The consultant recommended continuing targeted clinical care management for high‑risk members.

Recommendations and next steps discussed

- Second‑opinion program: Apex recommended offering an optional second‑opinion service (Apex works with Mayo Clinic and MD Anderson) to help members with complex or uncertain diagnoses. Apex said MD Anderson’s second‑opinion service for cancer has no added charge to the county and can provide expedited input for cancer care decisions.

- Wellness and preventive outreach: Commissioners and staff reviewed the county’s recent wellness program and biometric screenings. Apex said preventive‑visit rates increased year‑to‑year and recommended continuing outreach to raise preventive screening and telehealth use, which can reduce higher‑cost ER and outpatient visits.

- Samaritan Fund and high‑cost claimant options: Apex described a market option the presenter called the “Samaritan Fund,” a voluntary program for very high‑cost members. Under the model described, an employer may pay a one‑time, employer‑funded transfer (Apex said $55,000 per qualifying employee in these materials) so the member can enroll in an individual market plan that the Samaritan Fund helps select and manage; dependents could be included for an additional per‑dependent fee (Apex cited $15,000 per dependent with an overall family cap). Apex and commissioners discussed the tradeoffs (employees get premiums and cost‑sharing covered in the individual plan; the county transfers one‑time funding and the member must elect to move). Apex said this is a voluntary, employee‑driven program, and that education and careful case selection are required.

- Telehealth and federal rule changes: Apex told the board of forthcoming federal rule changes affecting HSAs and telehealth, including allowing certain direct‑primary‑care fees (up to $150 per person/$300 per family per month in the presenter’s summary) while preserving HSA eligibility, and a permanent extension of the telehealth exception for many high‑deductible plans beginning Jan. 1, 2026. (Presenter phrased the package informally; staff and commissioners agreed to review formal federal guidance.)

What the county will do next

Apex said it will provide more detailed rebate accounting once Prime Therapeutics’ calculations are finalized (Apex estimated pharmacy rebates lag claims by several months). Apex also offered to run a pre‑renewal strategy meeting to dig into high‑cost claimant cases, network options (high‑performance networks), biosimilar strategies, and potential clinics or reference‑based designs if the county wishes to pursue them further.

Speakers

- Lauren — senior account executive and principal, Apex (presenter) - Sage Muffin — Kinetic Health program manager, Apex (clinical presenter) - Andy May — director of client engagement, Apex - Dottie — county staff (benefits/human resources; identified in meeting as the county’s HR/benefits point of contact) - Jim — Commissioner (questioner) - Bill — Commissioner (questioner) - Susan — Commissioner (participating)

Authorities

- Internal Revenue Service rules on HSA eligibility (referenced by Apex in the presentation)

Discussion_decision

- Discussion points: specialty pharmacy spend and GLP‑1 usage; stop‑loss placement and fixed‑cost savings; pharmacy pass‑through rebate contract; wellness and telehealth programs; Samaritan Fund as an optional strategy for very high‑cost employees. - Directions (nonbinding): staff to schedule a prerenewal strategy meeting with Apex; Apex to supply the Samaritan Fund materials and further rebate accounting; staff to consider second‑opinion enrollment materials and employee education on telehealth and direct primary care options. - Decisions: no formal change of plan design was voted at the meeting; the commissioners received the annual review and asked staff to continue studying the options presented.

Clarifying details

- Reported fixed‑cost savings from negotiations: about $323,000 (Apex’s figure combining stop‑loss and admin changes as presented to commissioners). - Reported negotiated organ‑transplant policy cost: ~$33,000 per year (fully insured). - Reported average enrollment for the plan year: ~214 employees (Apex reported an average enrollment figure during the presentation). - Reported high‑cost claimant counts: Apex identified 10 high‑risk members at year end; three members with active cancer management were noted.

Proper_names

[{"name":"Apex","type":"business"},{"name":"Prime Therapeutics","type":"business"},{"name":"Companion Life","type":"business"},{"name":"PHP","type":"business"},{"name":"Optum","type":"business"},{"name":"Lincoln","type":"business"},{"name":"Mayo Clinic","type":"organization"},{"name":"MD Anderson Cancer Center","type":"organization"},{"name":"Parkview","type":"organization"},{"name":"Samaritan Fund","type":"other"}]

Searchable_tags

["health benefits","pharmacy","stop loss","Apex","telehealth","Samaritan Fund","DeKalb County"]

Provenance

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