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Apex: DeKalb County health plan costs jumped; brokerage recommends shopping carriers and carving out pharmacy
Summary
Apex Benefits told commissioners that DeKalb County’s self‑funded plan is running well above prior‑year claims—medical paid claims rose to about $1.36 million vs. $888,000—and pharmacy accounts for roughly 30% of spend. Apex recommended issuing RFPs for third‑party administrators and pharmacy benefit managers, evaluating narrow networks and alternative plan designs, and presenting renewal options in May.
Lauren McMahon, Apex account executive, presented an executive financial summary and clinical report showing that the county’s health plan is trending materially above prior years. "Medical gross spend on paid claims so far this year is $1,360,000, where the prior plan year we were at $888,000," McMahon said. She and Apex colleague Bill Sylvester pointed to multiple recent large claimants and rapidly rising specialty‑drug costs as primary drivers.
Apex reported that pharmacy now accounts for roughly 30% of total plan spend and highlighted several high‑cost specialty medications and ongoing claimants (including an aortic aneurysm and hemophilia treatments) pushing the plan’s net spend above expected levels. "We're seeing a lot of specialty pharmacy activity and several ongoing high‑cost claimants that we need to manage," McMahon said.
Apex outlined a multi‑step strategy: issue an RFP for TPAs and networks, evaluate narrow‑network options (e.g., Parkview‑focused arrangements) to obtain deeper hospital discounts, carve pharmacy out of the TPA where feasible to gain transparency and rebate pass‑throughs, and consider plan‑design changes such as higher deductibles or wellness incentives. Bill Sylvester quantified the scale: "Your cost per employee per year is trending at $18,959 — that puts you at the high end among our county clients," he said.
Commissioners asked detailed questions about implementation impacts (step therapy, grandfathering) and service problems the county has experienced with some ancillary insurers. Apex committed to taking medical renewals to market immediately, returning early May with renewal results and modeled contribution scenarios for commissioner decisions ahead of open enrollment.
Next steps: Apex will issue RFPs and return with carrier/TPA/pharmacy options and contribution modeling for a May renewal strategy meeting.
