LaSalle County consultants flag pharmacy savings and stop‑loss risk as renewal approaches; Rx Solutions shows ~$136,000 benchmark gap

Dave Heaton of Rx Solutions presented the county’s rolling‑12‑month pharmacy analysis and benchmark repricing, telling the LaSalle County committee the county’s net employer pharmacy cost (after rebate credits used in the analysis) was roughly $1.3 million and that Rx Solutions’ repricing shows a potential savings opportunity of approximately $136,000 versus their benchmark.

Heaton said the county’s top drug by plan cost is Mounjaro (transcript spelled differently), with roughly $204,000 attributed to that product in the most recent rolling period; GLP‑1 injectable drugs (Mounjaro, Ozempic) and other type‑2 diabetes medications were among the highest nonspecialty drivers. He recommended careful prior‑authorization criteria to limit substitution of diabetes indications to obtain weight‑loss formulations and emphasized that biosimilar adoption (for drugs such as Humira and Stelara) should reduce net specialty costs when providers and members transition.

Horton Group and Heaton cautioned the committee that Blue Cross Blue Shield of Illinois requires a 500‑employee minimum to allow a standalone pharmacy carve‑out; LaSalle County’s plan size (reported at roughly 443–446 employees on different slides) currently limits the ability to capture the full savings that a pharmacy carve‑out could deliver without moving medical coverage as well. Heaton described Rx Solutions’ fee model: a $23,000 fee is built into the analysis but is charged only if negotiated savings exceed that threshold; there is no fee if their negotiated savings are under that amount.

Horton Group’s monthly report also covered plan performance and renewal risk. She reported the plan is running at about 86.3% of expected through May (a favorable early‑year position) but noted the plan’s history of high‑cost claims in prior years and that stop‑loss underwriting could increase significantly at renewal (Horton Group said stop‑loss increases of 30–50% were possible given recent claim experience). Horton Group recommended aggressive market shopping starting July 1, review of stop‑loss and cooperative options, continued promotion of wellness solutions including Vida, and engaging Rx Solutions for PBM contract review and negotiation.

On vendor contract optimization, Horton Group recommended trimming unused services from HealthJoy to reduce PEPM from $13.20 to approximately $8.70 by removing bill review and mental‑health bundles the county rarely uses; HealthJoy agreed to that change if the contract is extended to 2029. Horton Group said EAP (CureLink) and core telemedicine benefits should be retained because the county relies on them and they would remain even if HealthJoy were replaced.

Horton Group presented a renewal timeline: the team will market the group starting July 1, expects to receive the renewal from Blue Cross in late July, and will bring final recommendations to the committee on August 27 (with the full board review to follow in September). The committee voted to accept and place the health insurance report on file and adjourned; Horton Group noted the Vita program will be brought back for an August vote.