Group Health Insurance Update January 2026
13.D.1.
Human Resources Director Suzanne Boyll, along with representatives from
Lockton Companies, presented insights on the County's Group Health Insurance
program for the plan year from October 1, 2025, to September 30, 2026. She
noted that the new Pharmacy Benefits Manager (PBM), Rightway Healthcare,
would now require prior authorization for GLP-1 medications for weight loss,
based on BMI and comorbidities.
Ms. Boyll stated that the previous plan year (October 1, 2024, to September 30,
2025) ended with a $2.5 million deficit, with medical claims up 19.2% and
prescription drug claims up 32.2%. The total medical claims amounted to $17.4
million, with 75 high-cost claimants responsible for $8.6 million, compared to 62
claimants the previous year. Prescription drug claims totaled $7.4 million, with
GLP-1 medications contributing $2.3 million (23% of total Rx claims). She noted
that the Health Insurance Trust Fund balance was $21,562,606 as of September
30, 2025.
Ms. Boyll responded to Chairman Loar, indicating that the affected members
regarding the changes to the GLP-1 medication had been notified. She noted that
staff would revisit this issue in March 2026.
Lockton Companies Pharmacy Specialist Tressa Chretien observed a decline in
the number of utilizers in the October data. However, there was a steady increase
noted in November and December. A significant factor to consider was the first
quarter of 2026, when the new prior authorizations took effect.
The Board and staff discussed newly emerging medications, particularly the tablet
version of GLP-1, which offered easier administration but had a similar price to its
injectable form, ranging from $149 to $450. Despite many qualifying for these
medications, the financial burden on employers and patients remained high.
However, direct-to-consumer options were emerging, offering lower prices than
insurance coverage. Mechanisms like HR cards were being developed to help
subsidize employee costs, which may have encouraged employers to reconsider
covering these expenses in health plans. Lockton was monitoring these trends to
guide future funding decisions.
Ms. Boyll touched on the popularity of the Health Center that was approved a
few years ago, but the return on investment was still 6 to 7 years away.
No Action Taken or Required