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County finance director urges caution after GLP‑1 drug costs spike; recommends staying with current PBM for now
Summary
Gaston County finance director presented RFP results showing specialty and GLP‑1 drugs are driving pharmacy costs and the evaluation team recommended keeping Prime Therapeutics for the coming plan year to avoid mid‑year disruption and potential rebate losses. The county will reassess after plan‑year start.
Kyle Sutherland, Gaston County finance director, told commissioners the county’s pharmacy benefit manager (PBM) procurement review found specialty drugs — though fewer than 1% of prescriptions — account for about 33% of drug spending and that GLP‑1 drugs had driven a dramatic year‑over‑year cost increase.
"Less than 1% of all of our prescriptions are in the specialty drug category, but it also represents 33% of our cost," Sutherland said, and he cited a rise from about $2.8 million to roughly $8 million in GLP‑1 claims over a one‑year review period. He described other drivers including a small number of very high‑cost claimants and changes in provider networks. The RFP process (issued Jan. 5, responses due Jan. 28) produced proposals from Prime Therapeutics, CVS Caremark/Express Scripts, Lavinity, and OptumRx; the evaluation team included county staff and the broker Mark 3.
Sutherland explained the evaluation weighed projected NetRx spend against potential rebate impacts and transition disruption. "Prime was the lowest cost," he said, and the team recommended staying with Prime through the plan year and reassessing later, citing risks from a mid‑year vendor change: new ID cards, formulary differences, accumulator resets, and integration timelines described by vendors. He noted an actuarial estimate of about $2.7 million in rebate loss if the county left its Blue Cross/Prime arrangement without negotiated concessions.
The board asked follow‑up questions about membership counts and retiree exposure; Sutherland said plan membership has been steady and the county budgets roughly $15,000 per employee annually for health coverage. No formal vote was taken; staff said Mark 3 notified vendors of the county’s near‑term path and Lavinity submitted a revised proposal afterward that altered integration assumptions and financial terms. The county indicated it will reassess vendor choices after the new plan year begins (Oct. 1) and as budget decisions clarify the self‑insurance posture.
