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Board reviews PBM and dental RFPs amid steep pharmacy cost increases driven by GLP‑1 drugs
Summary
Keenan and SJVIA staff reported five PBM and five dental proposals; consultants said plan pharmacy costs rose ~22% year over year with GLP‑1 drugs and specialty prescriptions a major driver, and the board discussed mail-order and step-therapy options.
Keenan consultants and SJVIA staff told the board on May 20 that proposals for dental and pharmacy benefit management (PBM) services are under review and that prescription costs have risen sharply, driven in part by GLP‑1 weight‑loss and diabetes drugs.
Eddie Barfield of Keenan said the RFP for dental coverage received five proposals by the May 12 deadline — from Anthem, Delta Dental, MetLife and Guardian — and Cigna declined to quote. The PBM RFP received five proposals by the May 19 deadline — from Empiricx Health, Express Scripts, CVS Caremark, MedImpact and Carillon Rx — while OptumRx declined to quote. Barfield said the proposals will be scored and finalists shortlisted during the week of June 9, with recommendations planned for the July 18 board meeting. “Our goal is to present final recommendations for both the dental and PBM providers at the upcoming SJVIA board meeting scheduled on July 18,” Barfield said.
Consultants presenting utilization data said total pharmacy plan costs increased about 22 percent comparing the referenced periods, with overall Rx claim counts up about 12 percent. The consultant highlighted that specialty drugs accounted for a large share of the increase; one quarter showed roughly 633 specialty scripts with nearly $2.5 million in associated costs. The presentation singled out GLP‑1 drugs (used for diabetes and weight loss) among the top cost drivers.
Board members pressed the PBM consultant on whether vendor performance matched commitments made in the RFP process, particularly around lowering specialty utilization and increasing generic substitution. One board member said the SJVIA had been told a vendor would “work to move people towards generic drugs” and called for a “true up” comparing vendor commitments in the RFP to actual performance.
Discussion also addressed program options to control costs in 2026, including required mail‑order for 90‑day maintenance prescriptions and step therapy for GLP‑1 drugs. Consultants noted clinical programs and manufacturer rebates had produced savings — for example, the patient-saver program returned over $330,000 in savings for May–December of the prior year and clinical programs produced nearly $7 million in savings for 2024 — but that the net plan impact has been upward pressure from specialty and GLP‑1 utilization.
Why it matters: PBM and dental vendor selections, and benefit design choices such as mandatory mail order or step therapy, can materially affect member access, plan cost and future premiums. The board will review finalist proposals and is scheduled to consider vendor selections at the July 18 meeting.
Board action: informational and planning; no vendor awards were approved at this meeting.
