Rutherford County committee approves Sigma as medical, dental, vision and pharmacy ASO

Rutherford County's risk management committee voted to approve Gallagher and county staff's recommendation to select Sigma as the county's third-party administrative (ASO) vendor for medical, dental, vision and pharmacy benefits, effective Jan. 1.

The motion to approve the recommendation was made by Mike Curtis and seconded; a roll-call vote resulted in 11 yes votes and one no (Michael Smith). County staff described a months-long RFP and evaluation process and said the committee's recommendation was based on a combination of cost, administrative considerations and continuity for employees.

Why it matters: The ASO decision determines who administers claims, the pharmacy benefit manager relationships and the appeals process for disputed or non-covered treatments. Risk management staff and Gallagher said the pharmacy evaluation included an independent pharmacist reviewer and that certain procurement issues remain to be finalized before the contract is executed.

Questions and clarifications during the meeting centered on a recent state law affecting pharmacy benefit managers and on how differences between PBM proposals can mask real cost differences. Mr. Elum, representing the county's risk management office, said the new PBM law had little impact on this procurement because of the timing of the legislation and Sigma's relationship with Evernorth, the PBM disclosed in Sigma's proposal. He also noted that proposal comparisons can hide differences such as drug-exclusion lists (one exhibit showed 642 excluded members and specific drug exclusions), which affect true apples-to-apples cost comparisons.

Members also asked whether the dental and vision lines were administratively linked to the Sigma medical bid and whether employees bear dental/vision costs. Staff said the dental and vision recommendations are self-funded and administratively tied to the Sigma medical bid and that, for vision and dental, employees pay the premiums (there is no county match).

Appeals and access: Committee members asked what recourse employees have when a prescribed medication has no generic or is not covered. Staff said claims decisions are governed by the plan document administered by Sigma, and an appeals process exists; Gallagher and county staff can assist in individual cases. The presenters said Sigma agreed to maintain a senior-level, dedicated remote representative for the county account as part of the procurement terms.

Next steps: Staff said rates and plan-design decisions will return to the committee at a future meeting; those items will be finalized after the procurement and will inform final cost estimates and employee notices.

Vote at a glance: Motion to approve Gallagher and the insurance and risk management department's recommendation to accept Sigma's ASO proposal; effective Jan. 1. Vote: 11 yes, 1 no (Michael Smith).