The Astonishing Healthcare Podcast

This "Best of '25!" episode of the Astonishing Healthcare podcast highlights Episode 58, which featured Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. We'll be back with a fresh new episode next week, but given the acquisition of Amino Health and launch of Judi Care, a unified "front end" pharmacy and medical care navigation solution, we think having an understanding of what the back end - or "chassis" - is capable of helps paint a picture of what the future of health benefits management can look like!Liya and host Justi Venneri dive into several recent updates to the Judi® platform, highlighting Judi's overall agility and how it aids in the administration of benefit plans for Capital Rx's clients. During the discussion, they also explore:Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.Judi's ability to ingest historical claims data for seamless onboarding of new clients.The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.How Judi Health aims to streamline member care and improve the patient experience.Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.Related ContentCapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformCapital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®How Our Favorite New JUDI Features Aid Pharmacy Benefit AdministrationAH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this special episode of the Astonishing Healthcare podcast, Capital Rx Co-Founder and CEO, AJ Loiacono, and John Asalone, Executive Vice President of the newly formed Judi Care (former CEO of Amino Health), join Justin Venneri in the studio for a discussion about Capital Rx's acquisition of Amino, a unique care navigation company. The conversation covers everything from the background on how AJ and John met to "What is care navigation?" and how Judi Care offers 1) health plan members (i.e., healthcare consumers) a differentiated way to take control of their individual healthcare journeys, and 2) plan sponsors and other payers a user-friendly, unified pharmacy and medical care navigation front end that empowers plan members to find the care they need, when they need it.We're incredibly excited about the future and the opportunity to meaningfully improve access to care and the overall health benefits experience while helping reduce costs. Capital Rx has evolved into an HBM - or health benefits manager - as a result of Judi® processing medical AND pharmacy claims (and supporting all related workflows in one system), and a unified front end that "puts quality, cost insights, and all of the benefits that your health insurance provides into one simple search box" is a natural extension of our enterprise health tech capabilities. We hope you enjoy learning more about our journey and evolving mission!Related ContentJudi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramCapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformCapital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025AH065 - The Bridge to Value-Based Care: Unified Claims Processing™, with Dr. Sunil BudhraniFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This episode of the Astonishing Healthcare podcast highlights two recent posters presented by Zachary Brunko, PharmD (PGY1 Managed Care Pharmacy Resident), and Nash Albadarin, PharmD, MBA (Associate Director, Clinical Programs Business Development), at AMCP 2025 and the 2025 PQA Annual Meeting, respectively. We won't give away the conclusions, but Zach explains the team's research on International Classification of Diseases (ICD) codes and how they evaluated the accuracy and reliability of ICD codes submitted on pharmacy claims. Additionally, they sought to identify patterns in ICD code submissions across client types, drug classes, disease states, pharmacy networks, and regions.Nash highlights how text messaging and pharmacist outreach to patients through Rx Enhance - a clinical program designed to improve adherence and close gaps in care - drove marked improvement in medication adherence in 2024 for commercial plan members with diabetes, hypertension, and high cholesterol. If you're interested in the potential to streamline processes and improve decision-making by using data like ICD codes, or the potential for tech-enabled clinical programs to improve health outcomes, this episode is for you!Reference Materials & Related ContentPoster: Evaluating ICD Codes on Pharmacy Claim Submissions: Are They Reliable?Poster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM PopulationAH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmDAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDPlease visit Capital Rx Insights for more information, including this episode's transcript!

This episode of the Astonishing Healthcare podcast is all about Pharmacogenomics (PGx), a critical component of precision medicine that ensures the medications prescribed to patients align with their genetic makeup.. To explain everything from what PGx is and barriers to broader adoption to the future state of integrated care, Burns Blaxall, PhD (Senior Vice President of Precision Medicine at Aranscia), and Caitlin Munro, PharmD (Sr. Clinical Programs Manager at Capital Rx), joined Justin Venneri in the studio.Burns and Caitlin discuss the growth of biomarkers on drug labels and use cases where PGx has been most helpful to date (e.g., behavioral health), the cost of testing, lack of insurance coverage and appropriate clinical guidelines, and the general level of physician awareness. They also dive into ongoing efforts to overcome the common barriers to using PGx and how Capital Rx is approaching the opportunity - leveraging Judi® - to bring PGx to employer plan sponsors and others who would like to offer plan members this option as part of the health benefits program. They also highlight the important role pharmacists can play on care teams and in the delivery of specialized care and acknowledge that regulation and legal action will help drive change and improve greater accessibility and usage of PGx tools, which, based on some of the stories shared, can transform the patient experiences and improve health outcomes.Related Content & Reference MaterialsValidation of Pharmacogenomic Interaction Probability (PIP) Scores in Predicting Drug–Gene, Drug–Drug–Gene, and Drug–Gene–Gene Interaction Risks in a Large Patient PopulationAH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Justin Venneri speaks with Kristin Begley, PharmD, Chief Commercial Officer at Capital Rx, about the evolving role of Pharmacy Benefit Managers (PBMs) and the rapidly accelerating shift in demand for an "unbundled," agnostic model. But what does unbundling mean? How does this approach help to avoid conflicts of interest? What parts of a pharmacy program can be carved out or unbundled to allow plan sponsors the freedom to design a plan that meets their unique populations' needs? Kristin answers these questions and more during the conversation, and she also explains what's so astonishing about the Trump administration's executive order aimed at addressing global drug price disparities!Related ContentReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Pharmacy Benefits 101: The Importance of the NetworkReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactSigns it is time to change your PBM vendor, and how to overcome common hesitationsAH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Mike Tate, one of the newest members of Capital Rx's commercial team, joins Justin Venneri in the studio to discuss the latest challenges and innovations in the healthcare market, and how he's approaching growth opportunities "west of the Mississippi." Mike explains why his region has been relatively slow to adopt self-funding strategies compared to the rest of the country (despite the great work of innovative brokers and consultants), how plan members - who are more informed than ever before - are pushing their employers' benefits teams to think creatively about their strategies, and why he's so exited about Judi Health™ and the alignment of clinical programs, data, and more. Why did Mike join Capital Rx? How is a rising "Healthcare IQ" impacting the market? What are plan sponsors thinking about strategically? Listen in to find out!Related ContentReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactCapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformWhy this benefit leader switched to a more modern, transparent PBMAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This episode of the Astonishing Healthcare podcast with Dr. Sunil Budhrani (Chief Innovation & Medical Officer) highlights the transformative potential of Judi Health™, the first Unified Claims Processing™ platform offering a combined medical and pharmacy benefit experience (with vision and dental soon to follow)! Why is unifying claim administration necessary to reach a value-based world? Well, everyone has been talking about VBC for years, and it's proved to be an elusive target. On Episode 7, Dr. Budhrani explained why pharmacy must be included in the equation along with providers, patients, and payers, and today we go a level deeper, explaining why "everything" - all the patient's data - must be in one system to be able to achieve better health outcomes at a lower cost. On AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani, we revealed what we're doing and why.Today, Sunil discusses our experience thus far - 5 months into our unified claims experience - and the importance of flexibility in plan design to achieve a plan's goals. He also explains how Judi Health helps to empower providers and the provider-patient relationship via a "transparent architecture." What should the experience be like for patients? How about the plan sponsor/HR team side of the equation? Tune in to find out and hear why Judi Health represents an "opportunity to see - and achieve - what many people in healthcare say cannot exist" (hint: it's a win for all stakeholders). Related Content:Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramCapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformAH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya LomsadzeReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Setting a New Standard for the Future of Pharmacy Benefit AdministrationFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This Astonishing Healthcare podcast episode features Bridget Mulvenna, who joins us in the studio again for an insightful discussion about addressing data access hurdles and utilizing pharmacy claims data. Building on her previous episodes, we dig into the "how" here - how can plan sponsors get their data, analyze it, and use it to make more informed decisions. It's encouraging that things are getting a little better out there, but data transparency and sharing remain top concerns for channel partners and plan fiduciaries alike; everyone is trying to understand what's driving costs higher within their plans (aside from GLP-1s, of course)!What data do you need? Who can/should do the analysis? What do contract definitions have to do with this? We cover it all, offering practical suggestions to hold partners accountable based on Bridget's experience.Related ContentWhy this benefit leader switched to a more modern, transparent PBM.AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganAH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric BrickerAH053 - Selling Pharmacy Benefits: Relationships, Rebates, GLP-1s, and More, with Bridget MulvennaFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, we welcome Jessin Joseph, PharmD, MBA, back to the studio. Jessin's focus on the pharmacy benefit administration side of the business and experience at Kentucky Medicaid and working with health plan clients inform the discussion about the impact the new administration and appointments in Washington, D.C., may have on health plan partners, MPPP (M3P), various models of Pharmacy Benefit Management (PBM) for Medicaid, including the single PBM and carve-out/unbundling approaches, and how the drug price benchmark can influence access to medication for plan members.In Episode 16 - The Intersection of Pharmacy, Government Requirements, and Medicaid, Jessin highlighted the momentum that discussions around single PBM seemed to have, and this time around, nearly a year later, he dives into why everyone is talking about unbundling the pharmacy benefit!Related ContentReplay: How You Can Leverage Modern Technology to Meet the CMS Medicare Prescription Payment Plan RequirementsPartnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management AH033 - Never Move Again™, a Paradigm Shift in Pharmacy Benefits, with AJ Loiacono (for more on unbundling)Please visit Capital Rx Insights for additional content, including this episode's transcript!

This encore episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Judi Health garnered much attention during our second annual Partner Summit, as Unified Claims Processing™ has the potential to help reduce up to $1 trillion of administrative waste and empower the provider-patient relationship.AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively.Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health's innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies.The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.Related Content:Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformCapital Rx 2025 Partner Summit Highlights: The Future of Claim Administration & Benefit ManagementSetting a New Standard for the Future of Pharmacy Benefit AdministrationSigns it is time to change your PBM vendor, and how to overcome common hesitationsPlease visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Spencer Kramer, Director, Client Services at Capital Rx, joins us in the studio to discuss an important aspect of plan sponsors' annual reporting requirements: Prescription Drug Data Collection - aka RxDC. We review key dates and where plan fiduciaries can find important data and updates, and Spencer shares his experience working with Capital Rx's clients and some suggestions to a) yield a smooth RxDC submission process and b) make use of the detailed data that plan sponsors are entitled to!As a requirement of the Consolidated Appropriations Act of 2021, RxDC demands detailed annual data submissions by plan issuers, TPAs, and others. Spencer explains the importance of starting early, understanding the data submission components, tackling coordination complexities, and ensuring accuracy. You'll want to be working with a partner here, not "just a vendor." Spencer emphasizes the importance of cooperation and maintaining detailed records to avoid friction and streamline the reporting process.Related ContentAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesAH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric BrickerVisit CMS.gov for RxDC-Related Resourceshttps://www.cms.gov/marketplace/about/oversight/other-insurance-protections/prescription-drug-data-collection-rxdcFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, we discuss how modern technology - Judi® - brings efficiency to the labor union market with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services), Christie Peperato (Manager, Payment & Operations), and Kelly Smith (Product Manager). Who knew that Capital Rx has an hours banking system? Why did we build one? Well, every hour a union worker works may be tracked and "banked" for benefits eligibility purposes. So, those hours and the accuracy of the reporting matter... a lot. And as Christie describes, it's been a manual, "painful" process forever. After Mike explains the unique needs of union clients and what hours banking is all about, Christie and Kelly dive into how this newly developed system alleviates the pain by automating the tracking of work hours and eligibility for health benefits and having everything, including payments, processed in one system. By removing the manual burden on union office managers and making it easy for contractors to submit the data, managers and plan administrators can focus on what matters most: taking care of members' needs. Want to help name the new system? Drop us an email.

For this special episode of the Astonishing Healthcare podcast, Andrew Barnell, CEO of Geneoscopy, joins Justin Venneri in the studio for an insightful discussion about colorectal cancer (CRC) screening in observance of National CRC Awareness Month! Andrew explains how he and his "very talented" sister, Erica Barnell, MD, PhD, co-founded Geneoscopy to develop diagnostic tests using RNA biomarkers extracted from stool samples. Their newly FDA-approved test, ColoSense™, provides a non-invasive alternative to traditional colonoscopies.Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses the urgent need for increased screening awareness and greater access to screening tools, noting that employers can help overcome barriers to screening through education and by encouraging engagement in wellness programs. Other topics covered include:Over 135,000 people are diagnosed with CRC every year, and despite CRC being one of the most preventable cancers with good long-term survival rates following treatment, 50,000 people die from it annually. Preventive screenings are increasingly covered with no patient out-of-pocket costs, but insurers' expenses are rising.Increasing early screening is crucial: 30-40% of eligible individuals remain unscreened, particularly in the 45-49 age group.Geneoscopy's decentralized clinical trial and overall use of technology to conduct its pivotal FDA approval study virtually, which increased patient diversity and efficiency.Regulatory challenges remain: FDA approval is just one step; Medicare coverage and guideline inclusion are key hurdles.Bringing targeted therapy approaches to autoimmune diseases like IBD to improve patient outcomes and reduce costs is Geneoscopy's next goal.Related ContentMultitarget Stool RNA Test for Colorectal Cancer Screening. Barnell EK, Wurtzler EM, La Rocca J, et al. JAMA. 2023;330(18):1760–1768. doi:10.1001/jama.2023.22231Pharmacogenomics (PGx) 101: What You Need to Know for Rx ProgramsReference Materials/Other Links (courtesy of Geneoscopy)Projected Impact and Cost-Effectiveness of Novel Molecular Blood-Based or Stool-Based Screening Tests for Colorectal Cancer. Ladabaum U, Mannalithara A, Schoen RE, Dominitz JA, Lieberman D. Ann Intern Med. 2024 Dec;177(12):1610-1620. doi: 10.7326/ANNALS-24-00910. Epub 2024 Oct 29. PMID: 39467291.Colorectal Cancer—Patient Version. National Cancer Institute (NCI)Productivity savings from colorectal cancer prevention and control strategies. Bradley CJ, Lansdorp-Vogelaar I, Yabroff KR, Dahman B, Mariotto A, Feuer EJ, Brown ML. Am J Prev Med. 2011 Aug;41(2):e5-e14. doi: 10.1016/j.amepre.2011.04.008. PMID: 21767717; PMCID: PMC3139918.Follow Geneoscopy on LinkedInFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Bloomberg Intelligence's Jonathan Palmer (Sr. Equity Analyst & Team Lead, Healthcare) joins us in the studio for a discussion about the work his team does and the evolving landscape of health tech. Palmer notes interest in Hinge Health's potential IPO and how the market's receptivity to tech-enabled healthcare companies has improved recently. While these companies face pressure to demonstrate profitability amid evolving market dynamics, there's optimism about innovation on several fronts. He also explains the impact of health policy uncertainty and questions about what the FDA, FTC, DOJ, and CMS will do on investors' ability to place bets: ambiguity causes market hesitation, and investors gravitate toward safe havens.The discussion also covers areas of focus for 2025, including:Palmer's favorite Vanguards of Healthcare podcast episodes and why he enjoys speaking with private company CEOs and venture capital leadersBiopharma Innovation, including GLP-1s, oncology readoutsMedTech Advancements like surgical robotics, cardioablation, and evolving insulin delivery systemsCapital Spending Concerns as US providers and China's healthcare sector are under scrutinyHealthcare Services: online pharmacy growth and Medicare Advantage trendsReference Materials Courtesy of Bloomberg IntelligenceNorth America Managed-Care Policy OutlookN.A. Health-Care Tech, Distribution: 2025 OutlookRelated ContentVanguards of Health Care: How Capital Rx is Fixing America's Broken Drug PricingAH057 - How First-Movers are Taking Control of their Health Plans in 2025, with Jeff HoganAH047 - What Project 2025, RFK Jr., and Dr. Oz Could Mean for the Business of Healthcare Under TrumpAH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom EveganFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. They dive into several recent updates to the Judi® platform, highlighting Judi's overall agility and how it aids in the administration of benefit plans for Capital Rx's clients. During the discussion, they also explore:Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.Judi's ability to ingest historical claims data for seamless onboarding of new clients.The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.How Judi Health aims to streamline member care and improve the patient experience.Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.Related ContentCapital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®Pharmacy Benefits 101: Prior AuthorizationsHow Our Favorite New JUDI Features Aid Pharmacy Benefit AdministrationAH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On Episode 57 of the Astonishing Healthcare podcast, host Justin Venneri welcomes Jeff Hogan, President of Upside Health Advisors, back to the show to discuss the major trends he observed in healthcare procurement and plan management in 2024 and areas of focus in 2025. Jeff highlights the evolving role of employer fiduciaries under the Consolidated Appropriations Act of 2021 (CAA), building on Episode 30 and re-emphasizing the necessity of real-time data access and process-driven strategic decision-making. He explains how employers must take greater accountability for healthcare spending, moving beyond reliance on traditional insurance networks (BUCAHs) and considering alternative care delivery models; and adds that provider organizations must adapt to align care delivery with consumer needs or risk obsolescence.The discussion also covers the increasing use of analytics - including platforms like HOMA Health - or outside resources, like Nick Welle explained on Episode 52, to help plan employer plan sponsors manage costs and their vendor contracts, PBM reform, and point solution fatigue. Finally, Jeff outlines key priorities for 2025, including fiduciary compliance, confirming the removal of gag clauses from contracts, and greater transparency in broker compensation to ensure better alignment between healthcare purchasers and providers.Related ContentReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganBest of '24! AH041 - ERISA Litigation Outlook and Meeting CAA Requirements, What Can Plan Fiduciaries Do?Signs it is time to change your PBM vendor, and how to overcome common hesitationsTo learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.Resources MentionedVizient - 2025 Trends Report: Strategy is (finally) back in the driver's seatPeterson Health Tech Institute - Virtual Musculoskeletal Solutions (June 2024)ICER - Peterson Health Tech Institute: Assessment Framework for Digital Health Technologies (Sept. 2023)Peterson Health Tech Institute - Digital Diabetes Management Solutions (March 2024)For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Justin Venneri chats with Angela Kalantarova, PharmD, a senior clinical programs manager at Capital Rx, about recent updates to Medicare's star ratings. Angela shares her path to Capital Rx and experience working in managed care and on clinical programs, and she explains what's new for 2025: star measures for polypharmacy and concurrent use of opioids and benzodiazepines.The conversation highlights the positive impact early interventions can have and how innovative enterprise health technology like Judi® allows for real-time insights. As CMS proposes changes, such as possibly removing the MTM - medication therapy management - measure or others like limiting initial opioid supply, having the flexibility to react quickly helps immensely. Angela also provides some strategic insights into how to navigate the evolving landscape and achieve superior ratings.Related ContentAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDPoster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist UseAH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, we explore the nuances of stop-loss insurance with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services). With premiums on the rise due to high-cost claims reaching levels actuaries never thought possible, self-insured plan sponsors need new options and better tools to monitor their costs. Mike, who is a healthcare actuary by training, discusses everything from "What is stop-loss?" and who it's for to what's driving high-cost claims to new heights, the rise of a pharmacy-only stop-loss option, and options plan sponsors have to mitigate risk when "it's not a good time to be in a risk-taking business." Mike comments on broader cost drivers, using GLP-1s as an example, preliminary book-of-business trends (2024 vs. 2023), the importance of surveillance on emerging claims, and more! Related News & Content:Sun Life sees stop-loss problems spiking: Will it force employers to buy fully insured coverage? (BenefitsPro)AH031 - Dissecting Pharmacy Cost Drivers and the Value of PMPM, with Kristin Begley, PharmD, and Mike Miele, FSA, MAAACapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformPlease visit Capital Rx Insights for more information, including this episode's transcript!

This episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Guests AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively. Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health's innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies. AJ Loiacono reflects on the journey of building Judi Health and the importance of firsthand experience in workflow optimization. Dr. Budhrani stresses the importance of transparency and collaboration among the stakeholders, underlining how Judi Health can break down silos to improve care delivery and outcomes. They offer practical examples of how Judi Health can work, such as diabetic-specific plan designs and improved workflows for cancer care.The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.Related Content:Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformSetting a New Standard for the Future of Pharmacy Benefit AdministrationReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Signs it is time to change your PBM vendor, and how to overcome common hesitationsPlease visit Capital Rx Insights for more information, including this episode's transcript!

On Episode 53 of the Astonishing Healthcare podcast, Bridget Mulvenne, VP of Business Development, joins Justin Venneri in the studio again to share highlights of her first full year of selling pharmacy benefit solutions ahead of her webinar on February 13: 5 Ways to Improve your PBM Procurement Process in 2025 (click here to learn more and register). They discuss the evolving healthcare landscape, regulatory pressures, expanding indications for GLP-1s, and the need for transparency in pharmacy benefits. Bridget shares stories from the field, explaining why focusing on drug manufacturer revenue and breaking the industry's dependence on rebates are so important and how modern technology helps provide real-time data access and actionable insights to plan sponsors. Previous AH episodes featuring Bridget:AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy CostsAH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget MulvennaBridget also shares insights on the evolving landscape of GLP-1 medications and their growing number of FDA-approved indications beyond diabetes and highlights the challenges plan sponsors face with coverage decisions, balancing short-term costs with potential long-term savings. Discussing Capital Rx's Never Move Again™ offering, Bridget emphasizes its flexibility and appeal to sophisticated plan sponsors.Related Content:Pharmacy Benefits 101: Pharmaceutical RebatesOur Single-Ledger Model™ - Pharma Revenue ExplainedAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganPlease visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Nick Welle, Partner & Chair of the Health Benefits Practice at Foley & Lardner LLP, joins host Justin Venneri in the studio for a discussion about ERISA and how employer plan fiduciaries can navigate a relatively complex set of responsibilities. With the recent developments around the J&J lawsuit and interest in how that may progress following the dismissal of the allegations, and questions swirling about i) what the Trump administration will do regarding the ACA and ii) CAA compliance and reporting, the timing couldn't be better to publish Episode 52.They dive into common traps Nick has seen employers fall into, processes and resources to leverage to show that "homework" - i.e., reasonable due diligence - is being done on the vendors providing services to the plan and its members, and much more. The ability to see and evaluate plan data and costs has never been more important!Note that Nick's comments on this podcast are his own personal comments and do not represent any views or positions of the clients of Foley & Lardner.Reference Materials for Plan SponsorsEmployer Checklist for New Health Plan Price Transparency Rules and CAAFinal Mental Health Parity Rules – Top Five Changes to the Status QuoRelated ContentAH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™The Consolidated Appropriations Act (CAA): Kudos to the Department of Labor (AJ Loiacono at ViVE)To connect with Nick, CLICK HERE.Please visit Capital Rx Insights for more information, including this episode's transcript!

For Episode 51 of the Astonishing Healthcare podcast, we spoke with Nick Opalich, CEO of HospiceChoice Rx. We learned about how end-of-life care is evolving in the U.S., including the roles pharmacy and technology play in the hospice industry. Nick and host Justin Venneri discuss some similarities between the hospice pharmacy benefit management (PBM) and commercial PBM spaces, such as the importance of a great pharmacy network and independent pharmacies, why the drug price index matters (NADAC vs. AWP), medication access, and disconnected systems.A former pharmacy owner himself, Nick explains the importance of helping hospice providers control drug spend, which is usually the second highest cost behind labor for providers, and reimbursement trends/pressure. He also touches on dispense fees, the potential to improve ePrescribing, and leveraging AI for enhanced reporting.Related ContentWhat is NADAC & How Does It Differ From AWP?Pharmacy Benefits 101: The Importance of the NetworkFor ReferenceHospice industry Facts & Figures (NHPCO, 2024)Thank you for listening, and check out Capital Rx Insights for more, including this episode's transcript!

On this 50th episode of the Astonishing Healthcare podcast, Capital Rx Vice President of Business Development Hope Nakazato, PharmD, joins Justin Venneri to discuss her observations, based on diverse industry experience, about the three most common friction points between plan sponsors and pharmacy benefit managers (PBMs): lack of execution, poor communication, and inflexibility. So, why have plan sponsors dealt with the status quo and rising costs for so long? Great question.Hope uses the book, "Who Moved My Cheese?", by Dr. Spencer Johnson, to explain the fear of change, as well as three things people can look for in a true partner who will work with them in a collaborative and generally supportive way. If a new PBM or other vendor is aligned, consistent, and future-proof, change won't be as scary as it may seem, and plan sponsors can make more strategic decisions benefiting the plan and its members. Hope also shares the advice she'd give her younger self, as well as the most astonishing thing she's seen over the years (hint: it relates to drug prices).Related ContentCapital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025Pharmacy Benefit Procurement: How to Ensure That Savings MaterializeReplay: 5 Ways to Improve Your PBM Procurement Process In 2024 (stay tuned for the 2025 edition!)5 Recommendations for an Optimal PBM Deal (free eBook)Please visit Capital Rx Insights for more information, including this episode's transcript!

On this Astonishing Healthcare podcast episode, return guests Heidi McKinnon, PharmD, CHC (Head of Compliance at Capital Rx), and Symara Schmidt, PharmD, PMP, CHC, BCGP (Director, Compliance Programs), join host Justin Venneri in the studio for another Pharmacy Benefits 101 discussion about Pharmacy Audits, including how pharmacy benefit managers (PBMs) and pharmacies can work together to avoid issues and improve compliance - it is possible!They explain everything from common audit triggers and types of audits to how the audits work and resources pharmacies can leverage to improve compliance and reduce friction/errors. Why are compliance executives at a PBM explaining all this? Well, it's an important topic, and there are misperceptions about pharmacy audits. There can be positive outcomes, and reducing fraud, waste, and abuse in the pharmacy supply chain is always a good thing.Related ContentAH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHCAH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JDReference MaterialsThe Capital Rx Pharmacy Provider ManualPHARMACY AUDITS, An Important Tool for Fighting Fraud, Waste, and Abuse and Protecting PatientsPAAS National - Home PagePlease visit Capital Rx Insights for more information, including this episode's transcript!

What better way to kick off 2025 than having Dr. Eric Bricker join us in the studio for Episode 48 of the Astonishing Healthcare podcast? Known for his entertaining and educational videos covering all sorts of hot topics in and around healthcare and employer/employee benefits, Dr. Bricker and host Justin Venneri discuss the issues of high-cost drugs and access to claims data - two topics he recently covered on AHealthcareZ - Healthcare Finance Explained - that should be top of mind for plan sponsors this year as pharmacy costs continue to rise.Dr. Bricker shares several ways employers, depending on their size and risk tolerance, may be able to navigate the challenge of rising pharmaceutical costs for orphan and other expensive drugs - including GLP-1s. He also explains how the RFP process can be used to secure the plan's claim data, which is necessary to meet fiduciary obligations.While every plan is unique, most plan sponsors face similar challenges that the traditional PBM model isn't flexible or aligned enough to solve. Dr. Bricker is astonished by the complacency out there, but he does see the potential for an acceleration in the pace of change this year and next... tune in to hear why, and check out the links below for more information!AHealthcareZ Reference VideosHigh Cost Orphan Disease Drugs ExplainedDo Employers Own Their Claims Data? It's Complicated.Related ContentReplay - Cracking the Code: Unraveling Specialty Drug Costs & PBM ProfitsHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganPlease visit Capital Rx Insights for more information, including this episode's transcript!

On this final encore episode of the Astonishing Healthcare podcast this year, we're replaying Episode 41, which featured three experts weighing in on rising litigation against employers and pharmacy benefit managers (PBMs) and was one of our most popular. We also want to take the opportunity to say, "Happy Holidays and New Year!" and thank our listeners and guests this year, including current and former colleagues; we couldn't have done it without you!In Episode 41, we discussed what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode built on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Related ContentAH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesSelf-funded plans ignore the Consolidated Appropriations Act at their perilFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

Episode 20 of the Astonishing Healthcare podcast caught some folks' attention, as it featured Capital Rx Co-Founder and CEO AJ Loiacono and 3 Axis Advisors President/46brooklyn Research CEO Antonio Ciaccia. It's an episode you must listen to if your work or interests involve drug prices in any way. NADAC - national average drug acquisition cost - was the focus of our discussion on this episode, which was among the most downloaded and streamed episodes in 2024, and with PBM reform and drug prices top of mind, what better time to highlight it?NADAC serves as a crucial price benchmark for our industry, providing freely available visibility and some level of understanding - a "source of truth" - of drug prices in the United States. Average wholesale price (AWP) and other indexes fail to reflect actual acquisition cost/supply chain economics but have prevailed for years. Is it the pharmacy benefits managers (PBMs)? Is it the wholesalers? At Capital Rx, we have always preferred to leverage NADAC whenever possible because of its numerous positive attributes. Tune in to learn more about the changes that occurred early in 2024, and you can click here to see the most recent updates to NADAC.Related ContentWhat is NADAC & How Does It Differ From AWP?Why Use NADAC-Based Pricing Over AWPMedicaid.gov - Drug Pricing (where NADAC lives)Please visit Capital Rx Insights for more information, including this episode's transcript, AND we'll add links to any new studies or documents that may interest you if you're a student of drug prices or a fan of NADAC.

This Astonishing Healthcare podcast episode covers the potential future of US healthcare policy under the Trump administration, focusing on the business of healthcare services and possible changes to Medicare and Medicaid, support for telehealth, solving workforce issues, and managing chronic diseases. Our guest from Episode 13, Redefining Virtual Care: A Blueprint for Effective RPM, Robert Longyear, Co-Founder of Avenue Health, returns to the show and shares his view from K Street after reviewing Project 2025 and evaluating what RFK Jr. and Dr. Mehmet Oz could prioritize in their roles.Robert shares the highlights of his analysis, including what he found most interesting and what he'll be watching for on payment policy (e.g., there's bipartisan support for payment reform and price transparency), potential changes to Medicare Advantage and Medicaid, pediatric care, how to reduce administrative burden and alleviate provider burnout, abortion policies, the use of artificial intelligence, and access to patient data. If health policy matters to you, this episode is a "must-listen!"Related ContentAnalyzing Health Policy Priorities under RFK, Jr. and Dr. Oz (Nov 27)What to Expect in Health Policy from the Next Trump Administration (Project 2025 Analysis; Nov 7)Digital Health Technologies in Rural Health: Bridging the Gap in Care Access and Delivery (Nov 26)AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom EveganVisit Health Tech Happy Hour for more of Robert's work.For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this Astonishing Healthcare podcast episode, Tom Evegan, Principal, National Consulting Leader, Life Sciences at RSM, a leading provider of tax, assurance, and consulting services in the US, joins Justin Venneri for a discussion about topics ranging from health policy to drug pricing and how to provide equitable drug access. Tom shares his background and path to RSM, explaining how his experiences at a major pharmaceutical manufacturer, pharmacy benefit manager (PBM), and a biotech launching a new therapy shaped his experience and aided him in becoming a "gross-to-net expert."Tom has helped hundreds of drug manufacturers launch, acquire, or divest assets and bring products from the regulatory phase to commercialization, so he's seen a lot and pays close attention to issues impacting drug prices and market access. Given his broad experience across the pharmaceutical supply chain, almost no topic is off the table. The conversation dives into the Inflation Reduction Act (IRA), the Chevron Ruling and 340B program, AI, why rebates likely aren't going anywhere soon, and the most astounding thing Tom's seen (hint: it relates to GLP-1s)!Related ContentHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldAH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget MulvennaWhat is NADAC & How Does It Differ From AWP?AH022 - Pharmacy Benefits 101: Pharmaceutical Rebates, with Ben SchusterTo connect with Tom or for more information about RSM's Life Sciences Group/Management Consulting Services, please visit:Connect with Tom Evegan (LinkedIn)Life Sciences | Industries | RSM USScaling at the Speed of Change: BiopharmaFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

Our first "Best of" Astonishing Healthcare podcast episode goes back to the beginning. For those who have been listening, "Thank you!" - we'll be back with a new episode next week. For new listeners, A LOT has happened since our co-founder and CEO AJ Loiacono kicked things off, including, but not limited to:New York City FC and Capital Rx Announce Sleeve PartnershipPrime Therapeutics and Capital Rx Enter Into Transformative Strategic AllianceCapital Rx's Customer Care Team Wins 5 Stevie® Awards for Customer ServiceCapital Rx Launches Never Move Again™, Enabling Self-Funded Plan Sponsors to Perpetually Access the Best Drug Prices Without Ever Having to Reimplement a PlanReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Fortunately, the overarching message/theme remains highly relevant, and AJ's experience and insights are always interesting to hear. Employer plan fiduciaries and health plans need aligned, focused, and unconflicted partners with next-generation technology to support their benefit programs (and operations) in a rapidly evolving environment. This goes well beyond just being transparent or passing through pharma revenue on the PBM side, which are bare minimum expectations at this point.All that said, Happy Thanksgiving, and if you like what you're hearing, please share the podcast with your network!For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Nisha Bhide, PharmD, joins Justin Venneri in the studio to discuss an integral aspect of pharmacy benefit management (PBM) - the formulary. They explore everything from what a formulary is to how they are created and P&T committees, why and how often they change, the role JUDI® plays in managing a formulary efficiently, and the difference between open and closed formularies.*Nisha also dives into how specialty drugs fit into the equation, utilization management tools like prior authorization (PA), the role of formularies in helping manage low-cost generic or high-cost brand lists, and more!Related ContentPharmacy Benefits 101: What is a Formulary?Replay - Cracking the Code: Unraveling Specialty Drug Costs & PBM ProfitsCapital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.*If you'd like to dive into the details of a formulary, check out Capital Rx's Freedom (Open) Formulary Lookup or Capital Rx's Liberty (Closed) Formulary.

On Episode 44 of the Astonishing Healthcare podcast, Andrew Gordon, LSW, joins host Justin Venneri for a discussion about the extensive primary research he's conducting on transparency and incentives in the U.S. Healthcare system. Gordon, who recently interviewed Capital Rx co-founder and CEO AJ Loiacono, explained how unexpected costs associated with an MRI sparked his curiosity, leading him to question why the healthcare system functions the way it does. He describes how he secured grants to explore - via 600+ interviews - what transparency means, where incentives are misaligned, fiduciary responsibility, and other factors that often contribute to patient confusion and wasteful spending.Why is payment expected regardless of a correct diagnosis? Does insurance need to be so confusing? Can the RFP process help set rational expectations? What's the best way to conduct primary research when everyone's time is at a premium? Andrew answers these questions and many more during today's discussion!Related ContentAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganPharmacy Benefit Procurement: How to Ensure That Savings MaterializeAH014 - The Rise of Conversational AI: Healthcare Search & Patient Journeys Will Never Be the SameAH007 - There's No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MDLinkedIn is the best way to get in touch with Andrew.For more information about Capital Rx and this episode, please visit Capital Rx Insights.

This episode of the Astonishing Healthcare podcast covers the ins and outs of two programs in the government sector - i.e., Medicare and Medicaid - and how modern technology JUDI® allows for more agility and flexibility in delivering care to Part D plan members and meeting CMS requirements. Capital Rx's Nash Albadarin, PharmD, explains changes to the Medication Therapy Management (MTM) criteria for 2025, which will increase membership, and provides an update on how MTM impacts Medicare star ratings. He also describes the purpose and structure of the Drug Management Program (DMP), which aims to help limit the risks associated with misuse and overuse of prescription drugs, namely opioids and other frequently abused, high-risk drugs. Additionally, Nash highlights the utility of these programs and their potential beyond the government sector, as MTM and mitigating the risks associated with opioids, for example, can help other plan sponsors better manage their populations.Related ContentPharmacy Benefits 101: What's the Drug Management Program (DMP)?AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDPharmacy Benefits 101: Medicare Star RatingsAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Capital Rx's Vice President of Provider Relations, Kasi Ortiz, joins Justin Venneri in the studio to discuss the network component of pharmacy benefits. They discuss how modern technology - JUDI® - allows for flexibility and customization of the network to meet plan sponsors' varying needs based on their unique member populations. The network - the retail, mail order, or specialty pharmacies that dispense prescriptions for patients - is a crucial piece of the benefit design puzzle, and plan sponsors have options. Kasi expertly breaks down this subject, covering everything from the basics to building a NADAC-based commercial network, adding pharmacies to the network, the importance of transparency and independence (i.e., not owning dispensing assets), and how clients weigh cost vs. quality. She also explains how our agreements and networks are like Legos® (for Never Move Again™)!Related ContentReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio CiacciaLearn more about Never Move Again™ HERE.For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, three experts weigh in on rising litigation against employers and pharmacy benefit managers (PBMs) and what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode builds nicely on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Stay tuned for more, and we'll add some new resources (scripts and checklists, for example) to the links as they become available!Related ContentAH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesSelf-funded plans ignore the Consolidated Appropriations Act at their perilFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, four women pharmacists across Capital Rx's teams join host Justin Venneri to celebrate #WPD2024! Amy Stockton, PharmD (our guest for Episode 6); Symara Schmidt, PharmD, BCGP; Lauren Carroll, PharmD, BCACP; and Marissa Miller, PharmD, discuss the significance of Women Pharmacist Day and highlight the progress women have made in the pharmacy field and how and why they are celebrating this unique holiday within American Pharmacists Month. The conversation highlights personal stories about their careers, including advice they'd share with their younger selves, how they balance their roles at work and home, the importance of mentoring the next generation of women pharmacists, the impact pharmacists have on patient care, and their hopes for the future!Related ContentAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDAH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Capital Rx's Samantha Custer, Director of Member Experience, and Jake Mulkey, Product Manager, join host Justin Venneri to discuss a niche, important aspect of Medicare Part D plans: Transition Benefits. What goes on behind the scenes to enable a plan member to receive uninterrupted care? What role does modern software - i.e., JUDI® - play in providing members with a temporary supply of their medication and meeting notification requirements? What makes for a great relationship between product teams and other business units?To answer these questions and more, Sam and Jake explain everything from how processes can be built into the adjudication process in JUDI in real time to the exchange of data and reporting surrounding the notifications that must be sent to plan members, per CMS requirements. Sam also explains how flexible JUDI is and that if CMS issues changes to any one part of the process, they can be adhered to "quickly and easily," or if commercial clients want to leverage the setup, it's no problem. Jake shares his views on building products in a modern platform and some things he's learned over the years that make for a good working relationship between product and other teams.Related ContentAH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDPharmacy Benefits 101: Medicare Star Ratings‍How Our Favorite New JUDI® Features Aid Pharmacy Benefit AdministrationHow Our Favorite New JUDI® Features Aid Government ProgramsFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In Episode 38 of the Astonishing Healthcare podcast, Formulary Operations Manager Libbi Green, PharmD, joins host Justin Venneri in the studio for a timely discussion about flu season. The conversation covers the background of flu season, this year's flu vaccines, the timing and importance of vaccinations, how the flu vaccine performed last season, predicting flu trends, and the availability of different vaccine formulations to accommodate patients' varying needs.Libbi also explains the role of pharmacies and healthcare providers in administering flu shots, emphasizing the importance of accessibility and preventing serious illness and hospitalizations, what's important for plan sponsors to consider for their populations, the vaccine production schedule, and what advancements we may be able to look forward to!Related Content/ArticlesResearch Results Show Promise Toward Development of a Universal Influenza Vaccine (Pharmacy Times; July 2024)Next-Generation Vaccines and Therapies for Seasonal InfluenzaImpact of the Inflation Reduction Act on Vaccinations: What Pharmacists Need to KnowHelpful ResourcesCDC Flu View - Weekly U.S. Influenza Surveillance ReportCDC - What to Know About Flu SeasonFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Kevin Sundquist, VP of Product at Capital Rx, joins host Justin Venneri to discuss the journey of a pharmacy claim, from the prescription at the doctor's office to the pharmacy counter. Kevin explains how JUDI® allows claims to be processed efficiently and transparently and why benefit design, network selections, and utilization management programs such as prior authorization ultimately dictate how easy it is for plan members to fill their prescriptions at their local pharmacies or through the mail. Kevin aims to help people find the best prices and live healthier lives.AH037 builds on Episodes AH027 and AH028 with Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration - our two-part What is Pharmacy Benefit Management? series that describes the importance of benefit design and configuration, as well as his webinar, The Story of a Claim. If you've ever wondered how products are developed and processes and workflows are refined to ensure medications reach patients smoothly and affordably or what a future with unified claims looks like, this episode is for you!Related ContentReplay – The Future of Pharmacy Claims Processing: A Deep Dive into a Modern Adjudication SystemPharmacy Benefits 101: Prior AuthorizationsHow Our Favorite New JUDI Features Aid Pharmacy Benefit AdministrationFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Joe Murad, CEO of Vida Health, joins host Justin Venneri and Capital Rx Chief Clinical Officer Sara Izadi, PharmD, in the studio for a discussion about glucagon-like peptide-1 (of GLP-1) medications and how partnering to manage cardiometabolic health can help plan sponsors control costs and keep their populations healthy. Joe and Sara review the latest data, including the rising prevalence of obesity and diabetes, GLP-1 discontinuation rates, the robust GLP-1 pipeline, and they highlight the innovative partnership between Capital Rx and Vida. Together, they explore the importance of appropriate patient management, education, and support, nuances of GLP-1 prescribing like dose titration, the role of digital health technology in achieving effective healthcare outcomes and coordinating care with other providers, and what to watch for in 2025.Related ContentHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldAH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget MulvennaGLP-1s are No Laughing MatterSourcesHow many adults with private health insurance could use GLP-1 drugs (KFF; 9/5)GLP-1 Receptor Agonist Discontinuation Among Patients With Obesity and/or Type 2 Diabetes (JAMA; 5/24)Poll: 1 in 8 Adults Say They've Taken a GLP-1 Drug, Including 4 in 10 of Those with Diabetes and 1 in 4 of Those with Heart Disease (KFF; 5/10)The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028 (IQVIA; 5/7)For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Justin Venneri speaks with Bonnie Hui-Callahan, PharmD, CDCES, Senior Director of Clinical Programs at Capital Rx, about the significance of clinical programs within the pharmacy benefit management (PBM) space. Bonnie explains how clinical programs serve as an "added layer of service" similar to after-school programs. They enhance the core functions of PBMs (claim administration) and help plan sponsors reduce costs, improve quality of care, enhance patient safety, and address prevalent health conditions within their populations.The conversation delves into the different types of clinical programs offered by Capital Rx, categorized into five key areas: utilization management, cost containment, patient safety, population health, and personalized care. Bonnie emphasizes that while many programs, such as opioid safety and medication therapy management, are standard across PBMs, there are also unique, in-house, and vendor-partnered solutions tailored to specific health conditions. She also highlights the potential benefits and importance of integrating pharmacy and medical claims, offers some key questions plan fiduciaries can ask, and reviews the results of a recent poster presentation by her team at the 2024 Pharmacy Quality Alliance meeting!Related ContentPoster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist UseAH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDPharmacy Benefits 101: Prior AuthorizationsFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Will Tafoya, Senior Vice President of Operations and the leader of Capital Rx's contact center, shares his views on building and leading an award-winning customer care team, which is available 24/7/365 to serve millions of pharmacy plan members. Will's passion for customer care and his team shines through, as he explains why hiring PTCB pharmacy technicians and other individuals with healthcare experience is so important, the benefits of a virtual call center (vs. brick-and-mortar), how customer care interfaces with clinical or other teams, and much more.Since member service and support are central to Capital Rx's new Never Move Again™, as as AJ Loiacono describes in Episode 33 - Never Move Again™, a Paradigm Shift in Pharmacy Benefits, Will and host Justin Venneri dive into topics including:Client-specific training (e.g., cultural training)Why JUDI®, Capital Rx's enterprise health platform, is a "one-stop-shop" for Will's teamThe importance of considering how members will react to AI and automationMeasures of success, including average speed of answer (ASA) and handle timeFinally, Will shares that advice that's been most influential to him over his 30+ years in contact center leadership. (Hint: it's something we should never stop doing!)For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, AJ Loiacono, co-founder & CEO of Capital Rx, joins Justin Venneri to discuss Never Move Again™, the recently launched "unbundled" pharmacy benefit administration solution for large employers. It turns out larger employer groups, TPAs, and other groups with 50,000+ lives are very similar to health plans, which value the flexibility and transparency an unconflicted administrator provides. Supported by JUDI®, our single scalable enterprise health platform and a world-class call center, plan fiduciaries now have an option that addresses the pain points of CAA compliance and the friction of switching PBMs over time.The program's transparent, flat-fee structure ensures no incentive to push more expensive drugs, leverage hidden markups, or otherwise profit at the plan's expense - aligning with the fiduciary duties under ERISA. JUDI Health is the solution's core, providing a fully integrated system that allows clients to use their preferred services - point solutions, other vendors, rebate aggregators, or even pharmacy network options.Never Move Again™ is a return to the original, independent role of PBMs, offering a more ethical and efficient future for U.S. healthcare.Additionally, and please forgive the shameless plug, AJ will join Josh Golden, SVP of Strategy here at Capital Rx, who we spoke with earlier this year about future-proofing your pharmacy benefit plan (AH008), on September 19, 2024, at 2:00 PM ET for an educational webinar explaining our new offering. Register here: Build a Lasting Pharmacy Benefit Strategy with Never Move Again™.Related ContentCapital Rx Launches Never Move Again™, Enabling Self-Funded Plan Sponsors to Perpetually Access the Best Drug Prices Without Ever Having to Reimplement a PlanViVE 2023 Highlights: What's Behind the Price Tag of MedicationAH032 - Prescription Rebates: Agreements, Guarantees, and More, with NPC's John O'Brien, PharmD, MPH, and Julie Patterson, PharmD, PhDLearn more about Never Move Again™ HERE.For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, we dive into the National Pharmaceutical Council's recent employer survey on rebates and rebate guarantees published in the AJMC, Prescription Rebate Guarantees: Employer Insights ((7/19/24). NPC CEO John O'Brien, PharmD, MPH, and Senior Research Director Julie Patterson, PharmD, PhD joined Capital Rx's Co-Founder and CEO AJ Loiacono in the studio for the discussion, which covered everything from how and why rebates have become so important to employers and traditional PBMs and what "pass-through" means to "the spreadsheet" and the difficulty in comparing traditional and more modern PBMs and how rebates impact a plan's net total cost.AJ and John highlight how PBMs manipulate drug prices through rebate incentives, resulting in higher costs for employers and patients, and Julie reviews the results of their survey, explaining why employers must "break the addiction to rebates." They emphasize the importance of transparency and the role of employer benefits consultants in PBM procurement and evaluation as well (at Capital Rx, we value objective, helpful advice on benefit design for our employees). Check out the survey and be sure to sign up for NPC's newsletter to follow their work - it sounds like there's a lot more to follow!Contact InformationSign up for the NPC This Week Newsletter: https://www.npcnow.org/subscribe-updatesCheck out the National Pharmaceutical Council on LinkedInConnect with John O'Brien, PharmD, MPH on LinkedInConnect with Julie Patterson, PharmD, PhD on LinkedInRelated ContentPharmacy Benefits 101: Pharmaceutical RebatesAH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy CostsOur Single-Ledger Model™ - Pharma Revenue ExplainedVisit Capital Rx Insights for this episode's transcript and additional content!

In this episode of the Astonishing Healthcare podcast, Justin Venneri sits down with Kristen Begley, PharmD, Chief Commercial Officer, and Michael Miele, FSA, MAAA, Senior Vice President of Insured Services, for a discussion about some of the finer points of pharmacy benefit management (PBM) procurement and pharmacy program cost evaluation, including how misaligned incentives can drive costs higher than they should be for plan sponsors. They delve into the misleading nature of focusing on unit costs and high rebates and advocate for a per member per month (PMPM) model to gain a clearer picture of true costs and hold PBMs accountable.Kristin and Mike suggest ways to update and improve legacy PBM evaluation methods, encouraging stakeholders to more carefully consider everything from the questionnaires leveraged to screen potential PBM partners to the true value of clinical programs for utilization management - such as prior authorization - and the actual number of units used to forecast spending.Related PMPM Content:AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmDPMPM - Is It the Best Way to Measure or Track Anything?PBM Procurement: A PMPM Guide for Plans Sponsors eBookVisit Capital Rx Insights for this episode's transcript and additional content!

In this episode of the Astonishing Healthcare podcast, Jeffrey Hogan, President of Upside Health Advisors, returns to the show for a timely discussion with Justin Venneri about why the timing is perfect for health plan sponsors and fiduciaries to engage their partners to secure necessary disclosure requirements and access to their data: it's renewal season! The Consolidated Appropriations Act (CAA) placed additional responsibilities on plan fiduciaries, including the need to make attestations. With gag clauses removed from contracts, the door is open. Jeff stresses the importance of analyzing the plan's data to make informed decisions and meet the fiduciary obligations. "The industry is craving trust," and fiduciaries need a trusted source of data and analytics to help them identify areas of waste and make changes that will benefit their plans. Whether it's pharmacy benefits, hospital spend, or the commissions paid to brokers/consultants, there's a unique opportunity to gain the insight needed and avoid the rising risk of liability right now.To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.Related ContentAH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesSelf-funded plans ignore the Consolidated Appropriations Act at their perilFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Nick Van Hook (VP, Commercial Markets) joins host Justin Venneri to discuss the pharmacy benefits selling season and the importance of building relationships and trust in B2B sales, especially in healthcare. They start with Nick's career journey - from pursuing a professional golf career and not knowing what a pharmacy benefit manager (PBM) is to consulting and, ultimately, Capital Rx - and then dive into the top questions and issues Nick fields and must address while building personal connections and closing deals with larger employers, including health systems and universities, where he tends to focus his time.Nick shares his insights on current market trends, such as the significant impact specialty drugs and GLP-1s are having on employers' overall plan spend. He also explains drug mix and how Capital Rx differentiates itself by leveraging JUDI® to maintain independence and administer aligned pharmacy benefit programs that meet clients' needs without the conflicts of interest that arise from owning dispensing assets and engaging in spread pricing., for example.Related Content:The Upside of a Single-Ledger Model™ in Pharmacy BenefitsAH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmDAH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna & How to Manage Pharmacy Benefit Spend in a GLP-1 World (Blog)Please visit Capital Rx Insights for more information, including this episode's transcript!

In this Part 2 episode of Astonishing Healthcare, Justin Venneri continues the discussion about what a pharmacy benefit manager (PBM) does with Capital Rx team members Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration. They dive deeper into the weeds and geek out on topics including benefit configuration, enhancements, and testing to be sure everything is set up correctly! They also explain how JUDI® is different and makes several aspects of the process far simpler than they've experienced in the past with legacy software solutions.Jillian and Jean also share their perspectives on the common challenges employers, for example, face when configuring and implementing a new PBM. They offer advice to ensure things go smoothly, emphasizing the importance of considering member experience. Last, Jean explains how JUDI's design enables the deployment of enhancements such as a new Medicare Prescription Payment Plan (M3P) solutions with relative ease.Related Content:AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1Government Programs: The True Meaning of Customization (with Jason Barretto)Pharmacy Benefits 101: Successful ImplementationsPlease visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration, join host Justin Venneri for part one of a two-part discussion about what pharmacy benefit management (PBM) entails. They describe the basics and then peel back the layers of what PBMs do to ensure that a prescription processes correctly - per your pharmacy benefit - so you can pay the correct amount at the pharmacy counter or receive your medication in the mail.Jillian and Jean also share their professional journeys within the PBM industry, highlighting how their roles and teams are central to configuring and testing plan benefits so that formularies, the network, and clinical programs are set up correctly. This informative episode sets the table for a deeper dive into the configuration and testing that go on behind the scenes!Related Content:AH001 - Building a PBM: Tech, Navigating Growth, and Delivering Value with AJ LoiaconoWhat Is the Role of a Pharmacy Benefits Manager (PBM)?Pharmacy Benefits 101: What is a Formulary?Please visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of Astonishing Healthcare, Alfonso Martinez, Director of Product Management at Capital Rx, joins Justin Venneri to discuss the transformative role APIs - application programming interfaces - play in the healthcare industry and the flexibility they offer plan sponsors and benefits administrators to be imaginative. He explains how APIs facilitate seamless integration, automate critical workflows, and empower real-time data access and exchange, significantly enhancing user experiences.Alfonso reviews several practical use cases and explains how an open platform like JUDI® is revolutionizing pharmacy benefits management without being too "salesy." Additionally, they touch upon the future potential of APIs in achieving value-based care by breaking down data silos and enabling integrated analytics, processing payments, and much more!Related ContentCapital Rx's JUDI® - The Beauty of an Open PlatformCapital Rx's Enterprise Health Platform Enables Healthcare Organizations to Meet The CENTERS for MEDICARE & MEDICAID SERVICES' M3P RequirementsAH007 - There's No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MDPlease visit Capital Rx Insights for more information, including this episode's transcript!

Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA), Krystalyn Weaver, PharmD, JD, joins host Justin Venneri for a discussion about pharmacists and expanding their scope of practice. She shares her insights on the role pharmacists can play in the healthcare system and highlights several positive developments recently, including Iowa changing the scope of practice to be a standard of care model and Tennessee passing a law that allows pharmacists to prescribe in a "slew of categories" without requiring additional regulations.Additionally, Krystalyn shares her thoughts on the importance of making progress at the federal level to allow pharmacists to be reimbursed by Medicare (ECAPS), the AMA's stance against the expansion of pharmacists' responsibilities, how to relieve the pressure on the pharmacy business model, what some pharmacies are doing to diversify their businesses and succeed, and much more.Related ContentAH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHCIowa governor signs legislation that modernizes the state Pharmacy Practice ActUnder new law, pharmacist scope of practice expands in TennesseePlease visit Capital Rx Insights for more information, including this episode's transcript!