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USI warns St. Charles Parish plan running above budget, flags prescription and large‑claim drivers
Summary
USI presented detailed plan experience showing net claims of $29.88 million last year and a forecast that the 2025–26 plan year could finish about 5% over budget, driven by pharmacy spend and several high-cost medical claims including a $450,574 case where the plan’s stop‑loss limit is $275,000.
USI consultants told the St. Charles Parish finance committee that the district’s self‑funded health plan ran roughly $29,883,004.69 in net claims for the last full plan year and that, when annualized through October, the current plan year is tracking several percentage points over budget.
“Last year, in our full plan year, we had $29,883,004.69 in net claims,” the USI presenter said during the committee meeting, adding that pharmacy costs currently represent about 32–34% of total medical spend. The presenter cited a backlog of claims released after spring contract negotiations — notably with Ochsner — and called out a single large October claim of $450,574 that will exceed the plan’s specific stop‑loss attachment; the plan’s stop‑loss is $275,000, meaning the district’s exposure on that claim is capped at that amount.
Board members pressed USI on whether higher costs were driven by negotiated rate increases or by utilization. USI said negotiated rates change at contract renewal, and that several factors — more enrollees than forecasted, retirees moved off the plan, and an uptick in high‑cost claimants — contributed to the variance. “If we forecast this out, we’re gonna end up for the year about 11% higher in net claims compared to '24–'25,” the presenter said when walking through the annualized projections.
The USI consultants also reviewed pharmacy trends and specialty agents that are contributing to spend, naming GLP‑1 drugs (Ozempic/Wegovy) and high‑cost biologics such as SKYRIZI and Stelara (and its biosimilar Weslana) among notable drivers. The consultants said prior authorization and other utilization controls are already in place through the PBM Optum, but they recommended the board and benefits staff reexamine plan design, formulary options, and alternative PBM arrangements in January when staff present options for 2026 plan design changes.
Administration and USI agreed to provide additional data requested by trustees — including stop‑loss reimbursement history and comparative trends — at a follow‑up presentation in January.
