The Nueces County self-funded health plan bases medical claim payment through a PPO managed care contract while Rx claims are paid through a traditional PBM payment model.
For the month of January 2025 paid claims were $1,576,153.10 out of which Rx claims were $509,244.37 representing 32% of total claim spend for the month.
Had the county been on a Reference Based Pricing – Cash Pay plan the percentage of Rx spend to total spend would have been much higher.
Paid medical claims would have been significantly less than the $1,066,909 expended through the county’s PPO plan. Generally, the pricing differential between PPO’s and RFP – Cash Pay plans range from 25-50%. Taking the low end of savings, under a PPO – Cash Pay plan Nueces County would have expended about $700,000 towards medical expenses while paying the same $509,244.37 for PBM managed Rx claims.
In that case Rx claims would have represented 72% of total plan spend.
Be careful when comparing Rx spend between plans as a ratio of total plan spend.
Bear in mind that claims generally reduce in January since calendar year deductibles must be met again and most elective surgeries were scheduled in the last quarter of the preceding year. Plan sponsors can expect lower claims in January with a gradual spike in claim through the summer months.
