Podcasts about PBM

Lisa Collier joins Ben Markland to talk about carrying forward a family business while continuing to build for what comes next. They discuss the lessons Lisa learned from her father, the importance of listening before building, and how innovation and technology are changing the pharmacy benefits space. Lisa also shares how personalized medicine, PBM strategies, and a 360-degree approach can help create better solutions for brokers, employers, carriers, and members.

In this episode of Employee Benefits and Executive Compensation: Preparing for 2027, Troutman Pepper Locke attorneys Lynne Wakefield and Heather Heath Ryan explore the rapidly evolving health and welfare plan landscape and what plan sponsors and fiduciaries need to consider heading into 2027. The discussion opens with a foundational overview of health and welfare plan governance and fiduciary best practices, including the critical distinction between settlor and fiduciary functions, and explains why robust governance structures are increasingly essential in today's legal and regulatory environment.From there, Heather and Lynne turn to the key developments driving risk and change for plan sponsors, including the surge in breach of fiduciary duty litigation involving prescription benefit managers (PBMs), voluntary benefits, and tobacco surcharges; new CAA 2026 disclosure and reporting requirements for group health plan service providers; proposed DOL regulations expanding PBM fee transparency; recent guidance on fertility benefits; anticipated guidance on mental health parity (MHPAEA) and overfunded VEBAs; and considerations related to GLP-1 coverage. Whether you are evaluating your PBM contracts, reviewing your voluntary benefits offerings, or building out your health and welfare plan committee structure, this episode offers practical insights to help your organization manage risk and prepare for the year ahead.Listeners can find updates on Trump accounts, executive compensation, and retirement plans in other episodes in the series. Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

In this special episode of This Week in Pharmacy, Todd Eury welcomes Vox, the PPN and RxPR Intelligence Officer, for a timely conversation about the forces reshaping pharmacy. Together, they examine the reimbursement pressures threatening independent pharmacies, the progress—and unfinished work—of PBM reform, and how artificial intelligence can augment pharmacists, strengthen operations, and create more time for meaningful patient care. The discussion also looks ahead to NCPA 2026 in Kansas City, emerging innovations from Hendren AI and FDB, YARAL Pharma's support of community pharmacy, and the upcoming Veterans Pharmacy Care Summit. The message is clear: pharmacists and pharmacy technicians must engage lawmakers, host pharmacy tours in 2027, and share the patient stories that demonstrate pharmacy's value. This is not our platform. This is your platform.

Guest: Iowa State Representative Brett Barker, PharmD — District 51 Guest Host: Todd S. Eury, Pharmacy Podcast Network Regular Host: Greg Reybold — on special assignment Sponsored by: American Pharmacy Cooperative, Inc. (APCI)   Iowa has delivered one of the most significant state-level victories in the continuing fight for pharmacy benefit manager reform.   On this episode of the PBM Reform Podcast, guest host Todd S. Eury sits down with Iowa State Representative Brett Barker, PharmD, a practicing pharmacist and representative of Iowa House District 51, for an inside look at the passage of Senate File 383 and what the new law could mean for independent pharmacies, employers, patients and the future of PBM regulation across the country.   Representative Barker brings a rare perspective to the discussion. In addition to serving in the Iowa Legislature, he is a pharmacist and pharmacy executive who understands firsthand the financial pressures facing community pharmacies. Barker served as one of the House floor managers for SF 383 as the legislation moved through the Iowa General Assembly.   The legislation cleared the Iowa House by a 75–15 vote after previously passing the Senate 36–14. Governor Kim Reynolds signed SF 383 into law on June 11, 2025, and its primary provisions became effective July 1, 2025.   SF 383 establishes substantial new requirements governing pharmacy benefit managers and their relationships with pharmacies, health plans and other payors. Among its provisions, the law addresses PBM reimbursement practices, pharmacy contracting, pass-through pricing, pharmacy appeals and disputes, network participation and protections intended to prevent discriminatory treatment of pharmacies.   One of the central themes of the legislation is greater transparency and accountability surrounding the flow of prescription-drug dollars. The law defines and establishes requirements involving pass-through pricing, in which payments made by a third-party payor to a PBM for prescription drugs correspond to payments made to the dispensing pharmacy, including applicable professional dispensing fees.   During the conversation, Todd and Representative Barker explore:   Why PBM reform became such an urgent issue for Iowa pharmacists and patients. What community pharmacies were experiencing financially before SF 383. How pharmacists, pharmacy owners and advocacy organizations helped educate Iowa lawmakers. The political battle surrounding the legislation and what ultimately helped generate bipartisan support. Why PBM reimbursement methodology is central to pharmacy sustainability. The importance of giving pharmacies meaningful mechanisms to challenge reimbursement and contractual disputes. The role Representative Barker's pharmacy background played in explaining PBM economics to fellow legislators. The opposition lawmakers encountered while attempting to move PBM reform forward. What other states can learn from Iowa's strategy. Why pharmacists need greater representation inside state legislatures. Whether Iowa's legislation could become a model for broader PBM reform nationwide.   Governor Reynolds described the legislation as an effort to bring greater accountability to PBMs and noted when signing the bill that Iowa was joining a growing number of states pursuing similar reforms.   For independent community pharmacists, the Iowa experience demonstrates something increasingly important: PBM reform is no longer simply a pharmacy reimbursement debate. It is becoming a healthcare access, competition and patient-care issue being fought state by state.   Representative Barker's story also highlights another major theme of the PBM Reform Podcast — the importance of pharmacists becoming directly engaged in public policy.   When pharmacists bring their clinical knowledge, business experience and patient relationships into state government, they can help lawmakers understand how policies written hundreds of miles away ultimately affect whether a pharmacy can keep its doors open.   Iowa's passage of SF 383 represents a major milestone in that movement.   About Our Guest   Brett Barker, PharmD, represents Iowa House District 51. He earned his Doctor of Pharmacy degree from the University of Iowa and has worked extensively in community pharmacy. His professional background gives him firsthand insight into pharmacy operations, prescription-drug reimbursement and the challenges facing independent pharmacies.   About the PBM Reform Podcast   The PBM Reform Podcast examines pharmacy benefit manager practices, prescription-drug economics, legislation and public policy affecting pharmacists, employers and patients across the United States.   The program features pharmacists, policymakers, healthcare executives, legislators and advocacy leaders working to create greater transparency, accountability and competition within the prescription-drug marketplace.   Sponsored by American Pharmacy Cooperative, Inc. (APCI).   Guest Host: Todd S. Eury Regular Host: Greg Reybold — on special assignment Production: Pharmacy Podcast Network   PBM Reform Podcast — following the legislation, the policymakers and the pharmacists fighting to change the prescription-drug marketplace.

Guest: Iowa State Representative Brett Barker, PharmD — District 51 Guest Host: Todd S. Eury, Pharmacy Podcast Network Regular Host: Greg Reybold — on special assignment Sponsored by: American Pharmacy Cooperative, Inc. (APCI)   Iowa has delivered one of the most significant state-level victories in the continuing fight for pharmacy benefit manager reform.   On this episode of the PBM Reform Podcast, guest host Todd S. Eury sits down with Iowa State Representative Brett Barker, PharmD, a practicing pharmacist and representative of Iowa House District 51, for an inside look at the passage of Senate File 383 and what the new law could mean for independent pharmacies, employers, patients and the future of PBM regulation across the country.   Representative Barker brings a rare perspective to the discussion. In addition to serving in the Iowa Legislature, he is a pharmacist and pharmacy executive who understands firsthand the financial pressures facing community pharmacies. Barker served as one of the House floor managers for SF 383 as the legislation moved through the Iowa General Assembly.   The legislation cleared the Iowa House by a 75–15 vote after previously passing the Senate 36–14. Governor Kim Reynolds signed SF 383 into law on June 11, 2025, and its primary provisions became effective July 1, 2025.   SF 383 establishes substantial new requirements governing pharmacy benefit managers and their relationships with pharmacies, health plans and other payors. Among its provisions, the law addresses PBM reimbursement practices, pharmacy contracting, pass-through pricing, pharmacy appeals and disputes, network participation and protections intended to prevent discriminatory treatment of pharmacies.   One of the central themes of the legislation is greater transparency and accountability surrounding the flow of prescription-drug dollars. The law defines and establishes requirements involving pass-through pricing, in which payments made by a third-party payor to a PBM for prescription drugs correspond to payments made to the dispensing pharmacy, including applicable professional dispensing fees.   During the conversation, Todd and Representative Barker explore:   Why PBM reform became such an urgent issue for Iowa pharmacists and patients. What community pharmacies were experiencing financially before SF 383. How pharmacists, pharmacy owners and advocacy organizations helped educate Iowa lawmakers. The political battle surrounding the legislation and what ultimately helped generate bipartisan support. Why PBM reimbursement methodology is central to pharmacy sustainability. The importance of giving pharmacies meaningful mechanisms to challenge reimbursement and contractual disputes. The role Representative Barker's pharmacy background played in explaining PBM economics to fellow legislators. The opposition lawmakers encountered while attempting to move PBM reform forward. What other states can learn from Iowa's strategy. Why pharmacists need greater representation inside state legislatures. Whether Iowa's legislation could become a model for broader PBM reform nationwide.   Governor Reynolds described the legislation as an effort to bring greater accountability to PBMs and noted when signing the bill that Iowa was joining a growing number of states pursuing similar reforms.   For independent community pharmacists, the Iowa experience demonstrates something increasingly important: PBM reform is no longer simply a pharmacy reimbursement debate. It is becoming a healthcare access, competition and patient-care issue being fought state by state.   Representative Barker's story also highlights another major theme of the PBM Reform Podcast — the importance of pharmacists becoming directly engaged in public policy.   When pharmacists bring their clinical knowledge, business experience and patient relationships into state government, they can help lawmakers understand how policies written hundreds of miles away ultimately affect whether a pharmacy can keep its doors open.   Iowa's passage of SF 383 represents a major milestone in that movement.   About Our Guest   Brett Barker, PharmD, represents Iowa House District 51. He earned his Doctor of Pharmacy degree from the University of Iowa and has worked extensively in community pharmacy. His professional background gives him firsthand insight into pharmacy operations, prescription-drug reimbursement and the challenges facing independent pharmacies.   About the PBM Reform Podcast   The PBM Reform Podcast examines pharmacy benefit manager practices, prescription-drug economics, legislation and public policy affecting pharmacists, employers and patients across the United States.   The program features pharmacists, policymakers, healthcare executives, legislators and advocacy leaders working to create greater transparency, accountability and competition within the prescription-drug marketplace.   Sponsored by American Pharmacy Cooperative, Inc. (APCI).   Guest Host: Todd S. Eury Regular Host: Greg Reybold — on special assignment Production: Pharmacy Podcast Network   PBM Reform Podcast — following the legislation, the policymakers and the pharmacists fighting to change the prescription-drug marketplace.

What if your company could significantly reduce prescription drug costs without changing its pharmacy benefit manager or taking medications away from employees?In Part 2 of The H.I.T. Podcast, host Toby Kennedy continues his conversation with Louis Gallucci, CEO of Limitless Consulting Group, about how employers can take greater control of prescription drug spending through smarter sourcing strategies.Louis explains why self-funded employers should look beyond traditional pharmacy benefit managers (PBMs) and explore alternative purchasing options that can benefit both their health plans and their employees.From analyzing pharmacy claims data to identifying high-cost medications and exploring alternative sourcing channels like GoodRx and Mark Cuban Cost Plus Drugs, this conversation provides practical insights for HR professionals, benefits managers, and business leaders looking to control healthcare costs.In this episode:Why employees should have more flexibility in how they access prescription medicationsHow identifying your five most expensive drugs can reveal potential savings opportunitiesUnderstanding the difference between clinical strategy and pharmacy procurementHow employers can explore lower-cost sourcing without necessarily changing their PBM or formularyWhy reducing out-of-pocket prescription costs can help employees access the medications they needHow to request and analyze pharmacy claims data to identify unnecessary spendingWhy transparency matters when managing self-funded health plans and fiduciary responsibilitiesLouis also shares a practical starting point for HR leaders: Request a report of your organization's 10 most expensive medications over the past 12 months. Then work with your broker or benefits advisor to explore alternative sourcing options.The goal isn't simply to spend less on prescription drugs. It's to help employees access the medications they need while making smarter purchasing decisions for the organization.

(00:00:00) 234: Denied: How Your Insurance Company Gets Rich Watching You Suffer (00:00:11) Welcome to Itchy and Bitchy (00:00:42) Doc Itchy Medical Pet Supplements (00:01:06) Insurance Frustrations and System Failures (00:02:27) The Broken Lens and Broken System (00:04:31) Insurance Woes and Personal Experiences (00:08:19) Pre-Approvals and Administrative Burdens (00:15:31) The High Cost of a Broken System (00:20:04) Concierge Care: A Growing Alternative (00:28:17) The State of Healthcare in the US (00:31:50) Medical Debt and Systemic Issues Welcome to American healthcare, where a college dropout in a call center overrides your doctor and an algorithm denies your chemo before lunch. This episode rips the curtain off the profit machine: prior authorizations, surprise bills, and "peer" reviewers who couldn't spell the disease they're denying. The receipts are ugly — physicians now grind through ~40 prior auths a week, burning 13 hours; 94% say it fuels burnout; and 1 in 4 doctors reports a denial caused a serious patient harm, up to and including death. Claim denials jumped 25% while AI quietly batch-rejects thousands at a time.Become a supporter of this podcast: https://www.spreaker.com/podcast/itchy-and-bitchy-podcast--4303608/support.Itchy & Bitchy: Have you felt dismissed, misdiagnosed, or gaslit by a broken medical system.  From gut health, hormones, autoimmune disease, chronic pain, holistic health, and alternative medicine ... medical gaslighting, patient advocacy , or misdiagnosis we'll call that too.  For chronic illness warriors, self-advocacy seekers: WE OFFER  No BS 

A specialty prescription can pass through a payer, PBM, hub, specialty pharmacy, provider's office, and manufacturer support program before the patient receives the first dose. At every handoff, critical time, information, and patient confidence can be lost.   In Episode 1 of this three-part series, Todd Eury and leaders from AcariaHealth and CassianRx examine where fragmentation often begins: the moment a specialty prescription is written and the prescriber loses visibility into what happens next.   The conversation explores AcariaHealth's use of the CassianRx ONE Journey physician portal to reconnect prescribers and their staff with the specialty pharmacy process. The platform provides NPI-scoped access to prescription status, shipment history, patient information, secure two-way communications, and document exchange.   The episode also examines why provider adoption is an experience challenge—not simply a technology challenge. Even the most advanced portal delivers limited value if it creates another login, adds complexity, or fails to provide immediate and meaningful information. Topics include: The true cost of status calls, faxes, and disconnected workflows Improving transparency from referral through dispensing Designing technology that prescribers and office staff will use Secure communication between practices and specialty pharmacies Scaling the provider experience across a national specialty operation The appropriate role of AI in specialty pharmacy workflows How provider connectivity can accelerate patients' access to therapy The episode closes with the series' recurring question: What is the one handoff you would eliminate? Episode 1 establishes the provider layer of the specialty journey before Episode 2 shifts attention to the person still navigating access, affordability, onboarding, and treatment—the patient.   Hosted by: Todd S. Eury, Pharmacy Podcast Network Featuring: AcariaHealth and CassianRx Chris Corsi - CEO CassianRx Paige Davis - Vice President Product and Client Success Peter Bergen - Acaria Health Vice President - Pharmacy Operations Jennifer Iverson - AcariaHealth Vice President, Product, Clinical and Data Strategy Series sponsor: CassianRx and the ONE Journey platform   One patient. One journey. Every stakeholder.

What would Medicare for All actually mean for American patients, doctors, and taxpayers? Tudor Dixon sits down with healthcare policy expert Sally Pipes, president and CEO of the Pacific Research Institute and author of The World’s Medicine Chest: How America Gained Pharmaceutical Supremacy—and How to Keep It, to examine the debate over Medicare for All and single-payer healthcare. Pipes draws on her experience growing up in Canada to discuss the trade-offs she sees in government-run healthcare, including longer wait times, physician shortages, healthcare rationing, taxes, and limits on patient choice. The conversation also examines healthcare systems in Canada and the United Kingdom, the cost of expanding government healthcare in the United States, Medicare and Medicaid reimbursement rates, and the impact of government policy on medical innovation. Tudor and Sally also discuss alternatives for lowering healthcare costs, including association health plans, increased competition, PBM reform, short-term insurance plans, and giving patients more control over their healthcare decisions. A major focus is Canada's healthcare wait times. The Fraser Institute's 2025 survey reported a median 28.6-week wait from GP referral to treatment, although that figure represents a survey-based measure across selected specialties rather than every Canadian patient's experience.See omnystudio.com/listener for privacy information.

**What if your pharmacy could recover money from claims that were reimbursed below your cost? Heather sits down with Kris from Pharmacy Marketplace to explain payment-floor laws, underwater claims, and how pharmacies can challenge PBM underpayments. Learn how the process works, why many pharmacies are still leaving money on the table, and how technology can make filing and tracking appeals far easier.**   **Show Notes:** 1. **Introduction** [0:00] 2. **Addressing Underpaid Claims** [4:12] 3. **The Pharmacy Marketplace Solution** [7:49] 4. **Onboarding and Implementation Process** [10:45] 5. **Subscription Model and ROI** [14:57] 6. **Data as a Tool for Advocacy** [16:43]   ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be a part of the Pharmacy Podcast Network**

Humboldt Health is breaking new ground with a specialized healthcare captive tailored specifically for cannabis businesses with 50 to 2,000 employees. Blackwell Captive Scott Byrne joins Blunt Business to full us in on the details on the plan offering enrollment on October 1st. By leveraging shared purchasing power and self-funding models, the program empowers employers with greater data transparency, cost efficiency, and design flexibility that traditional carriers rarely offer. The plan integrates modern solutions—such as 24/7 virtual behavioral health, Outfox AI-driven provider navigation, and the five-PBM "Bwell RX" coalition aimed at curbing pharmacy expenses and reclaiming drug rebates. We also look at the future of cannabis reclassification and thus possibly how operating under state-level regulations could open the door for future medical marijuana coverage as industry acceptance expands.Advertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Prescription drug costs are climbing—but the medication itself may not be the biggest problem. It may be how and where you're buying it.On this episode of The H.I.T. Podcast, Toby Kennedy welcomes longtime friend Louis Gallucci, CEO of Limitless Consulting Group, for a deep dive into one of the biggest challenges facing employer-sponsored healthcare today: pharmacy costs.With 20 years of experience across group benefits, carriers, voluntary benefits, benefits technology, and consulting, Louis explains why employers need to rethink the way they purchase prescription drugs—and start looking at healthcare through the lens of procurement.Pharmacy now represents a significant portion of overall healthcare spending, and Louis shares how a surprisingly small number of medications can account for an enormous percentage of a health plan's total costs.In this episode:Why prescription drug spending has grown so dramaticallyHow just a handful of medications can drive a huge portion of plan spendingWhy the sourcing channel can matter as much as the medication itselfUnderstanding the enormous pricing differences that can exist for the same drugWhy rebates and traditional PBM strategies may no longer be enoughHow alternatives such as direct sourcing are changing the pharmacy landscapeWhy HR leaders should start thinking more like procurement directorsWhat self-funded employers need to understand about their fiduciary responsibilitiesWhy employers need to take ownership of their claims dataThe questions employers should be asking their PBMs and benefits partnersOne of Louis' biggest messages is simple: employers are the buyers.Your PBM may administer the claims, but employers need to understand what they're purchasing, where the money is going, and whether there is a more efficient way to source the same care.And there's a personal connection to this episode, too—Toby and Louis go back nearly 20 years, from working together early in their careers to attending each other's weddings. Now they're sitting down to unpack how dramatically the benefits and pharmacy landscape has changed.

Specialty Pharmacy Access, Innovation & Independent Pharmacy Growth   This Week in Pharmacy, we explore specialty pharmacy, pharmacy innovation, emerging career opportunities, and new business models for independent community pharmacy.   Today's episode is sponsored by Clearway Health, Value Drug Company, and FDB (First Databank, Inc.)   First, Allison Arant of Clearway Health joins us to discuss the next phase of specialty pharmacy within hospitals and health systems.   As rare disease and specialty therapies become more complex, health systems are looking for better ways to improve medication access, strengthen continuity of care, and keep patients connected to trusted clinical teams.   Todd and Allison discuss how health-system specialty pharmacy can expand community access and improve management of complex and rare disease treatments.   Learn more: https://www.clearwayhealth.com/   National Association of Specialty Pharmacy (NASP) #inSPire2026   Next, we preview inSPire 2026, taking place September 22–25, 2026, at the Gaylord National Resort & Convention Center in National Harbor, Maryland.   The specialty pharmacy community will come together to discuss medication access, emerging therapies, technology, patient services, clinical care, and the continued evolution of specialty pharmacy.   The Next Dose Summit   Then we welcome Jordan Smith, PharmD, AAHIVP, CPGx, and Melinda Fowler, RPh, ABAAHP, FAAFM to preview The Next Dose Summit, happening October 14–15, 2026.   RxPR and the Pharmacy Podcast Network are proud press and media partners.   The event focuses on innovation, entrepreneurship, leadership, emerging career pathways, and new opportunities for pharmacists looking beyond traditional roles.   It is designed for pharmacists, students, entrepreneurs, and healthcare leaders asking one important question:   What's next for pharmacy — and what's next for me?   Register here: https://www.jscommunitycare.org/store/p/2026-the-next-dose-summit-registration   Expanding Independent Pharmacy   Finally, Rick Seipp, PharmD, President and CEO of Value Drug Company, returns to discuss creative strategies for expanding independent community pharmacy.   Todd and Rick explore cash-based pharmacy, transparent pricing, clinical services, new revenue streams, and other non-PBM-dependent models that can help independent pharmacies diversify and grow.   The conversation focuses on how community pharmacies can strengthen their businesses while continuing to serve as trusted healthcare destinations.   Learn more: https://www.valuedrugco.com/   Sponsored By   Clearway Health https://www.clearwayhealth.com/   Value Drug Company https://www.valuedrugco.com/   First Databank — FDB https://www.fdbhealth.com/   TWIRx — This Week in Pharmacy is hosted by Todd S. Eury and produced by the Pharmacy Podcast Network — Amplifying the Voice of Pharmacists & Our Profession.

In this episode, Suzanne Spradley and Chase Cannon explore the growing interest in value-based pricing models for health plans, including bundled payments, capitation, and outcome-based arrangements. The two discuss how these models aim to connect payment with quality and cost outcomes, while highlighting the ERISA fiduciary, contracting, PBM transparency, HIPAA, and plan document considerations that sponsors should evaluate before adopting them. Listeners will come away with a practical understanding of both the promise and the compliance challenges of moving beyond traditional fee-for-service arrangements.

The next big lawsuit headline in employee benefits may not name the employer first. It may name the broker.We sit down with Ron Peck, Chief Legal Officer at The PHIA Group, to make sense of rising ERISA fiduciary liability pressure on self-funded health plans and the advisors who support them. The twist Ron keeps coming back to is that the legal “ingredients” have been around for years, from retirement plan cases to suits targeting TPAs and other service providers. What's changing is the target list, plus the creativity of plaintiffs' firms applying an established ERISA playbook to health plan cost drivers and vendor relationships.We get practical about what actually creates fiduciary status: discretion, control, and decision-making power over plan assets or administration. A disclaimer in a contract helps only if our behavior matches it. That leads to concrete safeguards brokers can use immediately, like documenting options, clarifying who makes the final call, and keeping our own records so a client can't later say “my broker made all the decisions.” From there, we connect fiduciary duty to cost containment basics that often get ignored, including subrogation and other recovery programs where leaving money on the table can look like a failure to follow plan terms and a failure of prudent asset management.Finally, we zoom out to what's next: PBM transparency pressure, out-of-network claims governance, and an emerging No Surprises Act risk where plans pay through the federal process when the claim never qualified. If you advise employer-sponsored health plans, this conversation is a must-listen for staying valuable without accidentally becoming the decision-maker. Subscribe, share this with a colleague, and leave a review with the biggest fiduciary risk you think advisors are underestimating.

Send us Fan MailGuest Bio Dr. Robert Hall | Medical Director, Optum Workers' Comp and Auto No-Fault12 years leading medical direction and formulary oversight at OptumPhysical medicine and rehabilitation (PM&R) specialist maintaining active clinical practice one day per week with injured workersStrategic voice on PBM industry trends, emerging drug therapies, and AI's role in claims prioritizationOur Conversation We explore pharmacy spending trends, compensability questions around new medications like GLP-1s and migraine medications, and how AI can help claims professionals prioritize without replacing judgment. Our conversation builds on CompPharma's 20th Annual Survey released earlier this year. Dr. Hall provided context from his unique PBM perspective.See the CompPharma 2025 Prescription Drug Management in Workers' Compensation SurveyKey Discussion PointsScript Volume Down, Per-Script Costs Up Prescriptions filled decreased 4%, yet per-script costs rose over 4%. Fewer generic opioids are available, causing providers to transition patients to more expensive alternatives. When lower-cost options aren't working, switching to higher-cost versions becomes the default.Opioid Decline Slowing Opioid spend dropped 7%—slower than the 13% annual declines of prior years. While fewer people are on opioids overall, those taking them can face additional complications such as opioid-induced hyperalgesia, where the pain medication itself makes pain worse. Providers unknowingly increase doses thinking pain is worsening, creating a spiral that drives costs and complexity.Efficiency Remains the Industry's Biggest Gap According to Dr. Hall, despite much progress, feedback from injured workers and treating providers is consistent: speed remains a big issue. Authorization turnarounds, surgery approvals, and medication approvals all lag. Efficiency directly impacts outcomes.GLP-1s: Compensability Questions Without Clear Answers GLP-1 medications (weight loss drugs) are appropriate when weight loss is necessary for surgery or when catastrophic injuries cause weight gain. But with 30-40% of adults overweight or obese, there's a strong incentive to route these expensive drugs through workers' comp claims instead of out-of-pocket. The core tension: just because a drug is medically effective doesn't make it work-related. Clear frameworks are needed to distinguish compensable uses from general health expenses.A parallel exists with migraine medications—highly effective for a common condition (10% of the population), creating similar pressure to tie them to workers' comp when they may not be compensable.Important caveat: GLP-1s carry real risks. Severe nausea, vomiting, diarrhea, pancreatitis, and hospitalizations have occurred. When complications arise, they become part of the claim, adding complexity and cost.PBMs Score Highest on Customer Service PBMs earned their strongest-ever customer service grades in this year's CompPharma survey. Relationships matter as much as technology. Speed, communication, and partnership mindset drive loyalty.AI Adoption Rising—But De-skilling Risk Is Real About one-third of respondents now use AI tools. The cautionary tale: radiologists improved cancer detection with AI, but their standalone diagnostic ability declined after using it. For workers' comp, AI's highest value is prioritization—flagging the 2 catastrophic claims out of 100 that need immediate attention. The goal is to free human judgment for complex decisions, not replace it. We need to keep using and challenging our brains. Early Identification of Catastrophic Claims AI could synthesize accident type, injury location, physician findings, diagnostic studies, and functional capacity to identify claims spiraling toward permanent total or catastrophic status before they explode in cost. Early intervention changes trajectory.The risk: "creeping catastrophic" claims. Injuries that seem manageable but don't close gradually become complex and expensive. Opioid dosing spirals, high-cost alternatives accumulate, and routine claims become catastrophic without anyone realizing when the shift happened.State Variations as a Learning OpportunityFor folks newer to workers' comp, Dr. Hall suggests the 50 different state regulatory frameworks aren't just learning obstacles—they're live experiments in how to approach injury treatment. Professionals entering the industry should embrace this complexity and diversity to build deeper medical and operational knowledge.The Motorcycle Pivot Dr. Hall learned to ride a motorcycle last year after walking away from the idea a decade ago (when a bike cost as much as new kitchen cabinets). He's now ridden 1,000 miles on quiet Sunday afternoons. ¡Muchas Gracias! Thank you for listening. We would appreciate you sharing our podcast with your friends on social media. Find Yvonne and Rafael on Linked In or follow us on Twitter @deconstructcomp 

**In Session 4 of the Ahead of the Curve Summer Webinar Series, Daniel East, CSO of Crystal Health Solutions, shares a scalable model designed to help independent pharmacies generate additional revenue without taking on the traditional costs of patient acquisition. If your pharmacy is looking for ways to diversify beyond traditional PBM-dependent revenue, improve cash flow, and build new patient volume without funding the entire acquisition process yourself, this session is worth watching.**   **Show Notes:** 1. **Introduction** [0:00] 2. **Pharmacy Profit Matrix and Daniel's Role** [3:44] 3. **Daniel's Introduction and Crystal Health Solutions** [6:59] 4. **Marketing and Telehealth Strategy** [9:51] 5. **Operational Details and State-Specific Considerations** [16:40] 6. **Onboarding Process and Next Steps** [24:31] 7. **Q&A and Additional Information** [33:54]   ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be a part of the Pharmacy Podcast Network**

How the 340B Drug Discount Program Quietly Raises Costs for Self-Insured Employers. Episode 527. Why should a self-insured employer care about the 340B charity program? That's the single question Stacey Richter puts to Shawn Gremminger, president and CEO of the National Alliance of Healthcare Purchaser Coalitions, in this episode—and his answer traces four ways the $68 billion program quietly drives up what employers and plan sponsors pay for drugs and medical care. From supercharged hospital consolidation to disappearing PBM rebates, Gremminger lays out why 340B, once treated as a niche topic, now sits squarely at the center of the drug pricing debate. WHAT YOU'LL LEARN ✅ Why 340B—now the second-largest drug purchasing program in the country at roughly $68 billion a year—matters directly to self-insured employers, not just to pharma and hospitals ✅ How 340B-driven hospital consolidation pushes up prices for all services, not just drugs, since hospital spend typically makes up 55–58% of total employer health plan costs ✅ Why 340B hospitals tend to mark up drugs even more aggressively than non-340B hospitals, and why 340B clinics disproportionately prescribe higher-priced drugs over cheaper alternatives ✅ How the Inflation Reduction Act's drug price caps are reportedly pushing some 340B entities to nonmedically switch patients toward non-IRA, higher-margin drugs ✅ Why employers lose access to PBM-negotiated rebates entirely whenever a drug is purchased through the 340B channel instead of the traditional channel ✅ Why Shawn Gremminger argues employers, purchasers, and policymakers need to stop treating 340B as a separate, carved-out issue from the broader drug pricing debate WHY THIS MATTERS Hospital spend already makes up more than half of a typical self-insured employer's healthcare costs, and 340B's distortions—inflated markups, prescribing skewed toward higher-priced drugs, and vanishing rebates—flow straight into that spend. A recent study found that for every point increase in hospital prices, non-healthcare employers respond by cutting payroll and jobs for middle-class workers. As 340B has grown from a niche $5–10 billion program into a $68 billion one, treating it as someone else's problem is no longer an option for anyone trying to understand or control drug pricing. MENTIONED IN THIS EPISODE Article: Brian Reid's Cost Curve Weekend newsletter, on pharma-hospital data-requirement lawsuits LinkedIn Post by Peter Hayes Article: "Reforming 340B to Serve the Interests of Patients, Not Institutions," by Anthony DiGiorgio, DO, MHA Article: "How a Company Makes Millions Off a Hospital Program Meant to Help the Poor," New York Times EP448 (Part 1 and Part 2) with Shawn Gremminger: Apple Podcasts | Spotify | Other Apps Study: Zack Cooper, PhD, on rising healthcare prices driving unemployment and job losses LinkedIn Post by Shawn Gremminger === LINKS ===

In this episode, Ezekiel Emanuel, MD, PhD, Architect, ACA, and Miriam Paramore, Health Tech CEO of RxUtility, discuss strategies to make prescription drugs more affordable, including generic drug access, price transparency, PBM reform and direct-to-consumer pricing. They also explore how healthcare can reduce administrative complexity while improving access, adherence and outcomes.

Schedule an Rx Assessment Welcome everyone to the Bottom Line Rewind, your monthly recap of the Bottom Line Pharmacy Podcast. This month, we feature interviews on topics about Inventory, AI and Automation, the Peptide PCAC meeting, R&D Tax Credits, and Basis when buying a pharmacy. Click below to check out the full episodes: Episode 1: Inventory Management in 2026 with Jared Barton, CEO of Inventory IQ Episode 2: Inside a Pharmacy AI Bot with Ross Miller, VP of Sales at TJM Labs Episode 3: R&D Tax Credit, Trump Accounts, Taylor Swift's Wedding Episode 4: Peptides, Policy, and PBMs with Dr. Anne West, Clinical Pharmacist at Atrium24, Dae Y. Lee, PBM & Pharmacy Practice Group Co-Chair at Buchanan Ingersoll & Rooney, P.C. Episode 5: Understanding Basis When Buying a Pharmacy with Ollin Sykes, CPA, CMA, CITP Stay connected with us: Facebook | Twitter | LinkedIn YouTube | TikTok | Instagram | Blog

Today's episode of This Week in Pharmacy — #TWIRx is sponsored by Value Drug Company and explores two major forces reshaping pharmacy: the evolution of the community pharmacy business model and the expanding role of artificial intelligence in medication optimization and value-based care.   PART ONE: The Impact of the Cash-based Community Pharmacy   Special Guest: Rick Seipp, PharmD President, Value Drug Company Community pharmacy is entering a new era.   In Part One, Todd Eury sits down with Rick Seipp, PharmD, President of Value Drug Company, to discuss the continued evolution and expansion of independent community pharmacy and the many different business models emerging across the profession.   Independent pharmacy owners are increasingly evaluating new ways to build sustainable businesses while creating greater professional freedom for pharmacists. One of the most interesting developments is the growth of cash-based and cost-plus pharmacy models that reduce or eliminate dependence on traditional insurance reimbursement and PBM-controlled prescription economics.   These models can give pharmacy owners greater control over pricing, patient relationships, clinical services and the overall direction of their businesses — while allowing pharmacists to practice with significantly less interference from insurance companies and pharmacy benefit managers.   Two pharmacies in the Pittsburgh region are demonstrating how powerful this model can become: Blueberry Pharmacy — Kyle McCormick, PharmD has built Blueberry Pharmacy around a transparent, cash-based model designed to simplify prescription pricing and create a more direct relationship between the pharmacist and patient. Forward Rx Pharmacy — Brandon Antinopoulos, PharmD is another emerging example of how pharmacists can create innovative pharmacy businesses built around transparency, accessibility and freedom from many of the traditional constraints of third-party reimbursement.   Todd and Rick discuss what these models mean for the broader independent pharmacy marketplace and why community pharmacy may be moving toward a much more diversified future.   Sponsored by Value Drug Company, a pharmacist-led wholesale distribution partner committed to supporting the continued growth and independence of community pharmacy. https://lnkd.in/ehf76qUs PART TWO: AI-Powered Medication Optimization   Special Guests: Yoona Kim, PharmD, PhD Co-Founder & CEO, Arine Jenny Behan, PharmD Lead Clinical Pharmacist, Arine In Part Two, #TWIRx shifts from pharmacy business innovation to one of the most important developments occurring in clinical pharmacy: the use of artificial intelligence to optimize medication therapy at scale. Arine is an AI-powered medication optimization platform designed to improve patient outcomes and reduce healthcare costs by helping ensure patients receive the most effective and appropriate medications. Listen to This Week in Pharmacy — TWIRx on the Pharmacy Podcast Network across Apple Podcasts, Spotify, Amazon Music, iHeartRadio, YouTube and all major podcast platforms. Pharmacy Podcast Network — Amplifying the Voice of Pharmacy.

In this episode of Benefits Bites, Mike and Madison unpack the pricing tactics that can make one PBM bid appear more competitive than another, from rebate credits and claim exclusions to specialty drug rebucketing and list management. Register for upcoming Employers Health webinars or watch on demand at https://www.employershealthco.com/resource-center/events/ Sign up for our monthly newsletter at https://www.employershealthco.com/#subscribe_cta Find additional helpful benefits strategies and resources at https://www.employershealthco.com/resource-center/articles/

How Discount Theater and Generic Compliance Ratios Quietly Overcharge Patients and Employers. Episode 526. Mark Cuban, co-founder of Mark Cuban Cost Plus Drug Company, and Cora Opsahl, managing director of Peterson Health Analytics and former director of the 32BJ Health Fund, join Stacey Richter for an outtake from their conversation last fall (EP488) on the operational mechanics of the pharmacy supply chain. They trace how a generic compliance ratio—typically requiring pharmacies to buy at least 92% of their generics from a single primary wholesaler—pushes independent pharmacies into paying a premium that gets passed straight to patients, and how so-called pass-through PBM contracts can pay pharmacies using one pricing formula while billing employers using an entirely different one. Along the way, they walk through the classic generic imatinib example—a drug Cost Plus Drugs sells for $25 a month that a traditional PBM channel has billed at $9,000—to show why a discount off an inflated reference price is, as Cuban puts it, discount theater. WHAT YOU'LL LEARN ✅ Why pharmacies get locked into overpaying: wholesalers set a Generic Compliance Ratio requiring pharmacies to buy at least 92% of their generics from them or face chargebacks and fees that wipe out their margin ✅ The classic generic imatinib example: Cost Plus Drugs sells it for $25 a month, while the same drug billed through a traditional PBM channel has run $9,000 a month—a "discount" off a $27,000 branded Gleevec price that Mark Cuban calls discount theater ✅ How specialty tiers compound the problem: because generic imatinib gets classified on a specialty tier, patients can owe 25% coinsurance calculated off the inflated WAC price rather than the drug's real cost ✅ Why a "pass-through" PBM contract isn't simple math: Cora Opsahl explains that PBMs often reimburse pharmacies on an acquisition-cost-plus formula while billing employers a completely different AWP-minus formula for the same claim ✅ Why claims audits keep finding money owed back to the plan—and why employers are often restricted to auditing only a pre-approved sample of 250 claims ✅ Mark Cuban's advice for the next RFP: simply requiring that Cost Plus Drugs be included in the network is often enough on its own to get PBMs to offer better rebates and terms WHY THIS MATTERS As Stacey Richter puts it, where there's mystery, there's margin—and pharmacy pricing is thick with both. Generic compliance ratios, WAC-based specialty tiers, and pass-through contracts that pay pharmacies one number while billing employers another all point to the same underlying reality: so much of what gets called an expense in medicine is simply pricing failure. For plan sponsors and brokers heading into their next RFP, understanding these mechanics—rather than accepting a discount off an inflated reference price—is what it takes to move from passive price taker to informed decision maker. MENTIONED IN THIS EPISODE EP429 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps === LINKS ===

In this episode of The Dish on Health IT, Tony Schueth, CEO of Point-of-Care Partners (POCP), welcomes Angel Ballew, Head of Pharmacy Clinical Programs & Services at Centene Corporation, along with Seth Joseph, Managing Director of Summit Health Advisors, and Jason Reed, Senior Consultant at Point-of-Care Partners, for a discussion about what it will take to scale pharmacist-delivered clinical services. The conversation builds on findings from the NCPDP Foundation-funded white paper, A Business Model Framework to Scale Pharmacy-Delivered Clinical Services, developed with contributions from Point-of-Care Partners and Summit Health Advisors. The research starts from an important premise: there is already significant evidence that pharmacist-delivered clinical services can improve patient outcomes. The harder question is how to make those services operationally and financially sustainable at scale. Tony begins by asking Angel about the role pharmacists can play in closing care gaps, particularly for vulnerable and rural populations. Angel notes that Centene serves approximately 3.5 million people living in rural communities, but emphasizes that access challenges extend beyond geography to transportation, housing, food insecurity, and other social determinants of health. Against that backdrop, pharmacists can be among the most accessible healthcare professionals in a community and may interact with patients more frequently than physicians or other providers. Angel describes opportunities for pharmacists to reinforce medication adherence, identify medication-related concerns, provide immunizations, support test-and-treat services, conduct screenings, and perform other clinical services. As states continue expanding pharmacists' scope of practice and provider recognition, she sees opportunities to further integrate pharmacists into the healthcare team, particularly in communities with limited provider access. Seth and Jason broaden the discussion by sharing what emerged from the stakeholder interviews and industry research behind the white paper. Pharmacist-delivered services are already being piloted or implemented across areas including gaps-in-care counseling, test-and-treat programs, medication counseling and medication therapy management, immunizations and preventive screenings, and chronic disease management. Jason notes that pharmacists can play an important role between physician visits for patients managing conditions such as diabetes and hypertension. The conversation then turns to one of the biggest obstacles to scale: reimbursement and credentialing. Angel describes the tension between generating enough patient volume to make participation worthwhile for pharmacies and demonstrating enough outcomes and value to justify health plan investment. She discusses Centene's work to make credentialing requirements clearer for pharmacy partners, including the internal education required to bring pharmacy into processes traditionally designed around other healthcare providers. Tony asks Seth what the research suggests needs to change. Seth explains that the findings pointed strongly toward health plans and pharmacies working together to lead the development of sustainable models. Pharmacy benefit managers remain important participants with established relationships, networks, technology, and processes, but Seth describes the difficulty an innovative program champion within a PBM can face when they must first secure a client and then assemble participating pharmacies. Health plans may have greater ability to initiate programs and bring the necessary parties together, although their different lines of business and geographic markets add their own complexity. Angel shares how some of this has played out at Centene. The organization has worked directly with pharmacy communities and industry partners, often state by state because of differences in pharmacist scope-of-practice requirements. At the same time, Centene has developed a national program with consistent quality measures and an infrastructure that can support additional pharmacy service opportunities. That experience provides a real-world look at what scaling can require. Angel describes participation approaching 73 percent nationally and nearly 30,000 pharmacies contracted to participate in the program, including growth of more than 10,000 pharmacies over the past several years. She points to consistency as an important part of building participation. Rather than continually replacing programs with something new, Centene has gathered feedback and iterated, helping pharmacy partners gain confidence that the opportunity is stable enough to warrant their investment. The discussion then returns to a central finding of the white paper: the “cold start,” or chicken-and-egg, problem. Pharmacies may hesitate to invest in technology, staffing, workflow redesign, and clinical capabilities until sufficient patient volume exists, while health plans want sufficient pharmacy participation before investing in programs and measuring outcomes. Meanwhile, differences in credentialing, enrollment, reimbursement, contracting, and reporting continue to create practical barriers. Tony introduces the concept of regional Pharmacy Health Alliances for Reimbursable Medical Services, or PHARMS, as one potential approach to addressing the cold-start problem by bringing health plans and pharmacies together within a geographic market. Angel agrees that the concept begins with the right problem. The industry does not lack evidence that pharmacists can improve outcomes or help address gaps created by provider shortages. What remains less aligned is the business model. She cautions, however, that health plan operations vary considerably across lines of business, patient populations, benefit designs, quality priorities, and state Medicaid requirements. A regional model therefore needs enough flexibility to account for those differences. Seth explains that this variation is precisely why the research pointed toward regional collaboration rather than attempting to solve every issue nationally at once. The goal is not necessarily complete standardization, but identifying enough commonality among health plans and lines of business to prioritize a smaller number of services and begin building the infrastructure needed to support them. Angel views those complexities as design considerations rather than reasons not to pursue regional collaboration. She also sees the potential for lessons and common approaches developed regionally to eventually contribute to greater standardization nationally, particularly within individual product lines. Jason brings the discussion back to the pharmacy perspective. Pharmacies need confidence that services will be reimbursed before they can reasonably invest in technology, redesign workflows, train staff, and begin documenting clinical care differently. Regional collaboration among multiple payers could give pharmacies greater confidence that those investments will support sufficient patient volume while creating value for patients, pharmacies, and payers. From there, the conversation moves to another critical requirement for advanced pharmacy practice: data interoperability. Tony points out that pharmacists cannot effectively close care gaps if relevant clinical information remains siloed. Angel agrees that pharmacists need timely, actionable clinical information and enough context beyond the dispensing system to intervene effectively. At the same time, she cautions against overwhelming pharmacists with more information than they can realistically use within their workflows. She also challenges the idea that interoperability must be an all-or-nothing proposition. While the industry continues working toward a more ideal interoperability environment, imperfect data exchange should not prevent health plans and pharmacies from making progress today. Jason expands on the interoperability challenge by discussing the emerging concept of a pharmacy EHR. Pharmacy management systems are highly effective at supporting medication dispensing and claims transactions, but advanced clinical services require additional information. He argues that the answer is not simply to deliver the entire EHR to the pharmacist. Instead, the industry needs to identify the minimum actionable clinical information pharmacists need to make better decisions and perform specific services. Just as importantly, Jason emphasizes that pharmacy interoperability must be bidirectional. Pharmacists increasingly generate clinically valuable information through patient interactions, and that information also needs to reach providers and other members of the care team. Angel notes that Centene already receives some information back from pharmacies, including through programs involving social determinants of health, although the more seamless bidirectional infrastructure envisioned by the group is still developing. Looking ahead five years, Seth describes himself as a “data-driven optimist.” He points to momentum across private-sector organizations, national and independent pharmacies, state governments, and policy initiatives. While significant reimbursement, policy, and infrastructure challenges remain, he believes many of the pieces needed to overcome the cold-start problem are beginning to come together. Angel shares that optimism. Her hope is that pharmacists become a much more integrated and visible part of frontline healthcare delivery. The COVID-19 pandemic demonstrated how accessible and valuable pharmacists can be when the healthcare system needs them, and she sees an opportunity to continue moving the profession beyond its traditional dispensing role. Jason adds that demographic pressures, including an aging population and primary care capacity challenges, will continue creating demand for pharmacists to practice at the top of their licenses. He expects states to continue expanding pharmacist prescribing authority and clinical roles while technology, interoperability, and potentially AI help pharmacies operate more efficiently and support broader clinical services. Tony closes with the question asked of every guest on The Dish on Health IT: what is one habit or perception healthcare stakeholders should change or revisit starting tomorrow? Angel challenges listeners to think about pharmacists as more than medication experts. They are also access experts. In a healthcare system facing provider shortages, increasing complexity, barriers to care, and pressure to improve quality, she encourages healthcare leaders to ask how they can better leverage one of the most accessible healthcare professionals available in nearly every community. Rather than focusing only on what pharmacists dispense, Angel leaves listeners with a broader question: What can pharmacists prevent or help solve? The episode closes, as always, with the reminder that Health IT is a dish best served hot. Prefer video? Catch episodes on the POCP YouTube channel

It's a mega episode.  We are joined by special guest New Jersey Assemblyman Roy Freiman, Chair of the Assembly Financial Institutions Committee. And we're talking about PBM reform in New Jersey and Assemblyman Roy Freiman's bill, A1502. This landmark PBM law has helped lay the foundation for the next generation of reforms to protect patients, pharmacies, employers, and taxpayers.But we still have work to do. And to help us we have co-hosts to help ask all the important questions you need to know.  

When should you drop an insurance carrier? It can be a scary concept, so how do you think through it? My guest today is a principal at an accounting firm focused on private practices. He helps his clients think through this question, among others, and he'll share his thinking with us. Joe Lessard is a partner at Professional Business Management, a healthcare practice management and accounting firm in the northwest Chicago suburbs. Joe has been with PBM since 2009 and a Principal since 2020. He has attained designations as a Certified Public Accountant (CPA), Health Practice Advisor (HPA), and as a Certified Healthcare Business Consultant (CHBC). He believes in rolling up his sleeves and is usually on site visiting his clients' operations first-hand. Joe is responsible for all accounting and payroll services as well as personal and business tax returns for his clients. He helps them review operations and day-to-day aspects such as HR, employee benefits, retirement plans, collections, billing, and patient interactions. Every client has different needs and that's why Joe's commitment to his clients' needs and his customer service is what he prides himself on. In this episode Carl White and Joe Lessard discuss Trends Joe sees in his clients in dropping carriers What the tipping point is to drop a carrier The high level before and after plan to drop a carrier successfully Want to be a guest on PracticeCare®? Have an experience with a business issue you think others will benefit from? Come on PracticeCare® and tell the world! Here's the link where you can get the process started. Connect with Joe Lessard https://www.linkedin.com/in/joelessardpbm/ https://www.instagram.com/thedoctorscpa/ For more depth on this episode, read Understanding and Managing Overhead Costs in Your Practice, a blog this guest wrote about it.  Connect with Carl White Website: http://www.marketvisorygroup.com Email:  whitec@marketvisorygroup.com Facebook:  https://www.facebook.com/marketvisorygroup YouTube: https://www.youtube.com/channel/UCD9BLCu_i2ezBj1ktUHVmig LinkedIn: http://www.linkedin.com/in/healthcaremktg

AJ spent two years selling health benefits with no customers and no references. His competitors told buyers their service was free. He charged a flat fee and told the truth about where the money actually went. Two years in, at $10M ARR, a Fortune 500 company called him. Judi Health just raised $400M at a $3.25B valuation.In this episode, AJ breaks down how he beat three Fortune 15 giants by operating 70% more efficiently, why he spent zero on marketing for two years and let customers sell for him, and the one hiring signal he refuses to ask about directly.Why You Should ListenWhy $10M ARR still felt like nothing against three Fortune 15 competitors.How to sell healthcare when your answer to "who are your customers" is "just you."Why he spent $0 on marketing and made customers the brand ambassadors.How he spots A players without ever asking them about the mission.Keywords startup podcast, startup podcast for founders, product market fit, finding pmf, Judi Health, Capital Rx, AJ Loiacono, pharmacy benefit management, PBM, healthcare startup, enterprise sales, transparent pricing, bootstrapping, self-insured employers, hiring for missionChapters00:00:00 Intro00:02:11 Why Healthcare Has No Shortcuts00:05:34 What Judi Health Actually Does00:11:27 Opacity As A Business Strategy00:15:12 Bootstrapping In A Regulated Market00:21:50 Selling The First Risky Customers00:27:15 Winning Bids When Rivals Look Free00:33:37 Zero Marketing And A Service Moat00:42:20 Hiring For Mission And A Players00:52:35 Founder Advice On Focus And DisciplineSend me a message to let me know what you think!

Mike sits down with CVS Health's Josh Fredell, senior vice president, PBM payor and life science solution, to discuss how one of the most well-known names in the pharmacy industry approaches biosimilars, formulary strategy and clinical management. Watch or listen to Benefits Bites and Healthcare Headlines.  Register for upcoming Employers Health webinars or watch on demand at Events - Employers Health. Sign up for our monthly newsletter here. Find additional helpful benefits strategies and resources at Articles | Employers Health.

Welcome back to our weekend Cabral HouseCall shows!   This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track!   Check out today's questions:    Anonymous: Good day Dr.Cabral, your doing great work! Can't imagine how proud your family and team are to have you. My question is regarding elevated CRP (didn't do HS-CRP) just did bloodwork for CRP. Which was 13. Also Lip (a) is 180.. which is high due to genetics. In combination.. A1C is creeping up at 6.1.. I know your not giving health advice however, what foods, products help? Berberine? Omega 3s? Thanks!       Matthew: Hi Dr Cabral-thanks for everything you do. My question is on turmeric. I have seen posts that turmeric supplements, especially those that also contain black pepper, are harmful to the liver. Do you agree? If so, what about turmeric that do not include the black pepper? If turmeric supplement's harm to the liver is higher than the benefit, do you have suggestions on a replacement? Thank you     Jasmine: I think my daughter has Lipedema, I've watched a few of your videos and have researched this topic but have never had this topic addressed: she drinks about a liter and a half of water a day, but doesn't urinate that much, never gets up at night, can go the whole day without. Is this affecting her Lipedema and any info you can share, your ideas/opinions would be appreciated. We do things holistically, no drugs unless absolutely necessary (emergency situations), and I don't think diuretics are the way to go. Thanks for any info, Jasmine       Andrea: Hi Dr. Cabral, What is your opinion of the laser therapy for the brain for improved cognition, lymphatic flow? I was made aware of PBM would love to know your opinion. Thanks for everything, grateful for you!       Anonymous: Good morning Dr.Cabral, How would you go about supporting the body naturally dealing with Hepatitis B (chronic).. This has unfortunately been undetected for years due to being born in East Africa. In turn, this long-term Hep B has lead to Hepatocellular caricoma.. However, after a lot of research, the root cause was the Chronic Hep B.. want to deal with this then support the body to shrink the liver mass. Thoughts? Not asking for medical advice. did the HTMA (was unremarkable) but noticing a bit of itching and upper abdominal pain.         Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community's questions!      - - - Show Notes and Resources: StephenCabral.com/3851 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!  

Send us Fan MailSchedule an Rx AssessmentA LOT has happened recently in the Peptide market, but what exactly is new with peptides, the FDA, and the future of independent pharmacy? On this episode of the Bottom Line Pharmacy Podcast, we're joined for our typical quarterly pharmacy update with  ⁨@atrium24⁩ . Annie West, Clinical Pharmacy Director and Dae Lee, PBM & Pharmacy Practice Group Board Co-Chair at Buchanan, Ingersoll & Rooney, P.C. to break down:The two-day PCAC meeting and the committee's recommendationWhat happens next in the FDA rulemaking process The dangerous peptide gray marketThe latest on PBM policyAnd more!Stay connected with Atrium24 and Dae Lee:Dae Lee LinkedInAtrium24 WebsiteAtrium24 LinkedInAtrium24 InstagramAtrium24 FacebookStay connected with us:FacebookTwitterLinkedInScotty Sykes – CPA, CFP LinkedInScotty Sykes – CPA, CFP TwitterBonnie Bond – CPA LinkedInBonnie Bond – CPA Twitter More resources on this topic: Podcast - Inside a Pharmacy AI Bot: Automating Independent PharmacyPodcast – Driving Independent Pharmacy Profitability in 2026 with Nicolette Mathey, PharmD, CEO of Atrium24Podcast – 2026 Quarter 2 Pharmacy UpdatePodcast – R&D Tax Credit, Trump Accounts, Taylor Swift's Wedding

The PBM Reform Podcast, sponsored by APCI, welcomes John Vinson, PharmD, Chief Executive Officer of the Arkansas Pharmacists Association, for a timely conversation with host Greg Reybold about the management of the TRICARE pharmacy benefit.   Express Scripts administers pharmacy benefits for TRICARE, the Department of Defense healthcare program serving more than 9 million active-duty service members, military retirees, and family members. In fiscal year 2023 alone, TRICARE spent more than $8 billion on prescription medications.   Greg and John examine concerns surrounding Express Scripts' administration of the program, including shrinking pharmacy networks, reduced patient choice, questionable contractor reporting, specialty-drug delivery oversight, and the consequences for independent and rural pharmacies.   A 2025 Government Accountability Office investigation found that:   TRICARE's minimum network requirement fell from 50,000 to 35,000 pharmacies. The network had approximately 13,165 fewer pharmacies in late 2024 than in late 2022. An estimated 380,000 beneficiaries may have been forced to find another pharmacy. The Defense Health Agency relied heavily on contractor-submitted reports that contained inaccuracies. DHA had not consistently audited the data used to evaluate beneficiary access. GAO's two corrective recommendations remain open as of August 2026, although DHA has begun adding reporting and auditing requirements.   The episode also addresses higher 2026 prescription copayments. For most non-active-duty beneficiaries, home-delivery copays are now $14 for generic formulary drugs, $44 for brand-name drugs, and $85 for non-formulary medications. At retail network pharmacies, the corresponding 30-day copays are $16, $48, and $85.   Greg and John discuss whether PBM-driven network reductions represent true savings—or simply transfer costs, inconvenience, and access barriers to military families and the community pharmacies serving them.   Key discussion points Express Scripts' role in administering the TRICARE pharmacy benefit Pharmacy network contraction and beneficiary disruption Access challenges facing rural communities and military families Inaccurate contractor data and insufficient federal oversight Specialty-pharmacy delivery and monitoring concerns Rising 2026 copayments and pressure toward mail order Arkansas' leadership in challenging PBM vertical integration The need for transparency, accountability, adequate reimbursement, and patient choice   Important clarification: TRICARE is administered by the Department of Defense and is distinct from healthcare and pharmacy services operated by the Department of Veterans Affairs.   Sponsored by APCI — American Pharmacy Cooperative, Inc.   Sources: U.S. Government Accountability Office, TRICARE's 2026 pharmacy-benefit update, official 2026–2027 pharmacy costs.

Independent pharmacies need partners they can trust—and patients need a prescription-drug system that puts access ahead of profits. In this episode of This Week in Pharmacy, Todd Eury welcomes Rick Seipp, PharmD, President of Value Drug Company, to discuss the importance of choosing a dependable wholesale distribution partner. Following Smith Drug Company's announced operational transition, Value Drug Company is prepared to help affected independent pharmacy owners evaluate their purchasing, distribution and operational needs while developing an orderly transition that protects continuity of service. For more than 90 years, pharmacist-led Value Drug Company has supported community pharmacies through transparent pricing, dependable distribution, collective purchasing power and programs designed to improve efficiency, growth and profitability. Rick explains how the company will provide transition assistance and regional gatherings where pharmacy owners can speak directly with Value Drug Company leadership. The episode also features a follow-up conversation with patient advocate Bil Schmidtknecht about the continuing fight for Cole's Act. Named in memory of Bil's son, Cole, the proposed reforms seek to protect patients from unexpected formulary and coverage changes that can suddenly make essential medications unaffordable. “Patients can't afford more delays, and lives should never be collateral damage in a profit-driven system,” Bil says. The discussion examines PBM accountability, medication affordability and why families must receive meaningful notice before coverage changes place lifesaving treatments beyond their reach. TWIRx News: Week Ending August 14, 2026 Employers Are Moving Away from the “Big Three” PBMs A new employer survey points to growing disruption in the PBM marketplace. Forty-six percent of surveyed employers reported using a PBM outside CVS Caremark, Express Scripts and Optum Rx—up from 37% the previous year. Employers are increasingly seeking transparent pricing, access to claims data and greater control over prescription-drug spending. Read the Axios report FDA Delays Major iPLEDGE Changes Until November The FDA has postponed implementation of updated iPLEDGE REMS requirements from August 8 to November 15, 2026, to allow additional system testing. The forthcoming changes are intended to reduce burdens on patients, pharmacists and prescribers while maintaining safeguards surrounding isotretinoin. Read the FDA iPLEDGE update   Episode Resources Value Drug Company transition-support announcement Value Drug Company transition assistance: 1-866-226-1772 Patient Protector Modern Medical Mafia: PBM Reform Pharmacy Podcast Network About the Guests Rick Seipp, PharmD President, Value Drug Company Bil Schmidtknecht Patient advocate and father of Cole Schmidtknecht  

Picolé De Limão é um quadro do canal Não Inviabilize. Aqui você ouve as suas histórias misturadas às minhas!Use a hashtag #Vazia e comente a história no nosso grupo do telegram: https://t.me/naoinviabilizePUBLICIDADE PETLOVE
Conheça o PBM, o primeiro Programa de Benefícios de Medicamentos para pets do Brasil. Basta ser cliente do Plano de Saúde e ter o Clube Petlove ativo no site. O desconto aparece direto nos produtos participantes (com o selo P+ ao lado do nome). Use PONEI50 e ganhe 50% de desconto na 1ª mensalidade.*Exceto Plano Leve. Promoção por tempo limitado. O cupom pode ser desativado sem aviso prévio conforme disponibilidade. Não acumulativo com outras promoções. Consulte a disponibilidade na sua região. Mais informações no site da Petlove.Link:  https://saude.petlove.com.br/?promocao=influencer&utm_source=instagram&utm_medium=influencer&utm_campaign=n%C3%A3oinviabilizeQUER OUVIR MAIS HISTÓRIAS? BAIXE NOSSO APLICATIVO EM SUA LOJA APPLE/GOOGLE, CONHEÇA NOSSOS QUADROS EXCLUSIVOS E RECEBA EPISÓDIOS INÉDITOS DE SEGUNDA A SÁBADO: https://naoinviabilize.com.br/assineEnvie a sua história bem detalhada para naoinviabilize@gmail.com, seu anonimato será mantido, todos os nomes, profissões e locais são trocados para preservar a sua identidade.Site: https://naoinviabilize.com.brTranscrição dos episódios: https://naoinviabilize.com.br/episodiosYoutube: https://youtube.com/naoinviabilizeInstagram: https://www.instagram.com/naoinviabilizeTikTok: https://www.tiktok.com/@naoinviabilizeX: https://x.com/naoinviabilizeFacebook: https://facebook.com/naoinviabilizeEdição de áudios: Depois O Leo Corta MultimídiaVinhetas: Pipoca SoundVoz da vinheta: Priscila Armani

Rae McMahan joins Over the Counter to discuss recent regulatory action involving CVS Caremark and the Federal Trade Commission, exploring what the collection of PBM reform efforts means for the greater pharmacy industry moving forward.

We welcomed Nash Albadarin, PharmD, Associate Director of Clinical Programs at Judi Health™, back to the studio to talk about the evolution of clinical programs and clinical consulting for Episode 114 of Astonishing Healthcare! What happens when a proactive clinical consulting strategy is employed? What questions should employers ask to evaluate clinical programs? What sorts of results are we seeing with high-touch programs for low-cost alternatives or risk mitigation? Nash discusses his new role at Judi Health and answers these questions, and many more. A pharmacist by training with over 10 years of experience in the PBM industry, Nash describes what a consultative, data-driven approach to clinical programs looks like in practice, and he backs it up with data and real-world examples that show hundreds of thousands of dollars in savings and meaningful reductions in opioid exposure for employers. He also describes a new site-of-care optimization program that's turning heads.HighlightsProactive clinical strategies drive meaningful results and help build trust. For years, PBMs waited for clients to flag a spending problem before responding. Judi Health™ is flipping that model, scrutinizing claims data so the team can bring vetted solutions to the table or contact plan members before red flags appear.The results are concrete and substantial. Recent biosimilar conversions drove $130,000 in annualized member savings and $850,000 in annualized plan savings, while Rx Ally cut short-acting opioid day supply by 14.3 days for enrolled members.Shifting care from medical to pharmacy - and the site-of-care - yields surprising savings. A newer clinical program, CareShift Health, optimizes site-of-care and shifts select medical drugs to the pharmacy benefit, resulting in a lower net cost.Unified data unlocks hidden savings. Medical and pharmacy spend have traditionally lived in separate silos. When you compare them side by side, the excess billing and administration costs tied to provider-administered drugs become clear, and clients are often "blown away" by what they find.Related ContentAH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmDHealth Benefits 101: The Importance of Clinical ProgramsReplay - Improving Metabolic Health in a GLP-1 WorldPoster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM PopulationHow PBMs are tackling behavioral health (Managed HC Executive)For more information about this episode and content from Judi Health, visit www.judi.health/insights.

Picolé De Limão é um quadro do canal Não Inviabilize. Aqui você ouve as suas histórias misturadas às minhas!Use a hashtag #Lagrimas e comente a história no nosso grupo do telegram: https://t.me/naoinviabilizePUBLICIDADE PETLOVE
Conheça o PBM, o primeiro Programa de Benefícios de Medicamentos para pets do Brasil. Basta ser cliente do Plano de Saúde e ter o Clube Petlove ativo no site. O desconto aparece direto nos produtos participantes (com o selo P+ ao lado do nome). Use PONEI50 e ganhe 50% de desconto na 1ª mensalidade *Exceto Plano Leve. Promoção por tempo limitado. O cupom pode ser desativado sem aviso prévio conforme disponibilidade. Não acumulativo com outras promoções. Consulte a disponibilidade na sua região. Mais informações no site da Petlove.Link:  https://saude.petlove.com.br/?promocao=influencer&utm_source=instagram&utm_medium=influencer&utm_campaign=n%C3%A3oinviabilizeQUER OUVIR MAIS HISTÓRIAS? BAIXE NOSSO APLICATIVO EM SUA LOJA APPLE/GOOGLE, CONHEÇA NOSSOS QUADROS EXCLUSIVOS E RECEBA EPISÓDIOS INÉDITOS DE SEGUNDA A SÁBADO: https://naoinviabilize.com.br/assineEnvie a sua história bem detalhada para naoinviabilize@gmail.com, seu anonimato será mantido, todos os nomes, profissões e locais são trocados para preservar a sua identidade.Site: https://naoinviabilize.com.brTranscrição dos episódios: https://naoinviabilize.com.br/episodiosYoutube: https://youtube.com/naoinviabilizeInstagram: https://www.instagram.com/naoinviabilizeTikTok: https://www.tiktok.com/@naoinviabilizeX: https://x.com/naoinviabilizeFacebook: https://facebook.com/naoinviabilizeEdição de áudios: Depois O Leo Corta MultimídiaVinhetas: Pipoca SoundVoz da vinheta: Priscila Armani

PBM Reform Podcast Sponsored by American Pharmacy Cooperative, Inc. (APCI) Host: Greg Reybold Special Guest: Ben Mudd, PharmD, Executive Director, Kentucky Pharmacists Association   Momentum for meaningful pharmacy benefit manager reform is building in Washington.   In this episode of the PBM Reform Podcast, host Greg Reybold welcomes Dr. Ben Mudd, Executive Director of the Kentucky Pharmacists Association, to examine the bipartisan Pharmacists Fight Back Act, H.R. 6610, and what its advancement could mean for patients, pharmacists, employers, and the future of independent pharmacy.   On July 22, 2026, the House Committee on Oversight and Government Reform reported the legislation favorably following a committee markup. Introduced by Chairman James Comer of Kentucky and Representative Jake Auchincloss of Massachusetts, the bill would establish new requirements for pharmacy benefit managers participating in the Federal Employees Health Benefits Program.   The proposed reforms would require participating PBMs to provide fair pharmacy reimbursement, apply manufacturer rebates toward reducing beneficiaries' prescription drug costs, prohibit patient steering to PBM-affiliated pharmacies, increase transparency, and establish penalties for noncompliance.   Greg and Ben discuss why the Federal Employees Health Benefits Program could become an important proving ground for broader PBM accountability and how federal action may influence commercial plans, state legislation, and future healthcare policy.   Episode Discussion   The conversation explores:   Why H.R. 6610 has attracted bipartisan support How PBM reimbursement practices threaten independent pharmacy sustainability The impact of patient steering and PBM-affiliated pharmacy networks Why manufacturer rebates should directly reduce patients' prescription costs What “fair reimbursement” must include to protect pharmacy access How enforcement provisions and financial penalties could improve accountability Kentucky's role in advancing pharmacy and PBM reform The connection between federal legislation and state-level advocacy What pharmacists should communicate to legislators and patients The remaining steps required before H.R. 6610 can become law   Dr. Mudd brings the perspective of a practicing community pharmacist and association executive who has worked extensively in pharmacy advocacy. A graduate of the University of Kentucky College of Pharmacy, he practiced in both chain and independent pharmacy settings before assuming leadership of the Kentucky Pharmacists Association.   Ben is running for Kentucky State Senate position this November. Lear more about his platform and issues most important: https://www.votemudd.com/meet-ben   Key Takeaway   PBM reform is no longer simply an industry debate. It is a patient-access, healthcare-affordability, pharmacy-choice, and community-infrastructure issue.   The Pharmacists Fight Back Act represents a significant federal effort to separate PBM compensation from practices that may increase drug costs, restrict patient choice, and financially disadvantage independent pharmacies. The legislation's advancement is an important milestone—but pharmacists must remain informed, engaged, and vocal as the bill moves through the legislative process.   Subscribe to the PBM Reform Podcast for continuing coverage of legislation, regulation, litigation, and advocacy shaping the future of pharmacy benefit management and community pharmacy.   The PBM Reform Podcast is sponsored by American Pharmacy Cooperative, Inc., supporting independent pharmacies and advocating for a more transparent, competitive, and patient-centered prescription drug marketplace.

Ask Me Anything: How Does GoodRx Actually Make Money, and Who Really Pays for the Discount?. Episode 522. A listener asked Stacey Richter a deceptively simple question: how exactly does GoodRx make money? To answer it, this AMA episode revisits a 2021 conversation with Ge Bai, PhD, CPA, professor of accounting at the Johns Hopkins Carey Business School and of health policy and management at the Johns Hopkins Bloomberg School of Public Health, recently nominated to serve as Assistant Secretary at the Department of Health and Human Services (HHS). Ge Bai lays out exactly how GoodRx turns pharmacy-PBM contract dysfunction into a business, and Stacey updates listeners on what's changed—and what hasn't—in the years since. WHAT YOU'LL LEARN ✅ Why GoodRx is purely a pricing platform with no pharmacy of its own—unlike Amazon, which operates its own pharmacy ✅ How PBM contracts requiring pharmacies to offer insurers their "best price" force cash list prices artificially high, the exact dysfunction GoodRx monetizes ✅ How GoodRx's network of contracted PBMs—including Express Scripts and OptumRx—collects a per-dispense fee every time a patient uses a GoodRx card ✅ Why pharmacies lose out twice: they never collect their high list price, and they still owe a fee to the PBM that "referred" the cash-pay patient to them ✅ What's changed since 2021: a wave of new cash-pay competitors like Mark Cuban Cost Plus Drugs, GLP-1-driven cash-pay behavior, and proposed legislation targeting "Most Favored Nation" (lesser-of) clauses in PBM contracts ✅ Ge Bai's recent nomination to Assistant Secretary at HHS, building on research she has used to testify before Congress and shape healthcare policy WHY THIS MATTERS GoodRx's entire business model runs on a single structural quirk: PBM contracts require pharmacies to keep their list price higher than any insurer's negotiated rate, which pushes cash prices artificially high for anyone without a coupon. As Stacey Richter puts it, this dysfunction "is sadly pretty much the same" today as when Ge Bai first explained it in 2021, even as new cash-pay entrants and proposed "Most Favored Nation" contract restrictions start to reshape the landscape. MENTIONED IN THIS EPISODE EP520 with Stacey: Apple Podcasts | Spotify | Other Apps EP517 with Stacey: Apple Podcasts | Spotify | Other Apps EP516 with Ophelia Johnson: Apple Podcasts | Spotify | Other Apps EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps === LINKS ===

Matt Jarvis is the SVP of Strategy in Lockton's national pharmacy practice. He has a PharmD (Doctor of Pharmacy) and has worked in both retail and consulting pharmacy roles. Matt is a subject matter expert in understanding current pharmacy market pricing, supply chain, and medication delivery to the consumer. He leads the development and implementation of innovative clinical solutions that drive optimal management in specialty drugs for Lockton clients. Mentioned on the ShowConnect with Matt Jarvis, PharmD on LinkedIn here: https://www.linkedin.com/in/mjarvispharmdWould you like O'Brien or Matt to discuss your company's pharmacy benefit plan? Reach out here: Contact O'BrienMatt and O'Brien discussed alternatives like Amazon Pharmacy and Mark Cuban's venture, Cost Plus Drugs. Timestamps(00:00:00) – Matt Jarvis, PharmD joins his colleague O'Brien McMahon on the People Business Podcast(00:03:48) – What is the structure of a pharmacy plan and how does it differ from the medical plan? What are the common misconceptions?(00:05:43) – What a PBM is and why does it exist? Why isn't pharmacy handled through the regular health plan?(00:08:12) – Why don't drug manufacturers sell directly to health plans and what the steps are from drug creation to pharmacy purchase?(00:09:44) – What is a formulary?(00:13:09) – Why is there is a disconnect between doctors prescribing medications and what's actually covered by a plan?(00:14:37) – What is the role of drug reps in the overall pharmacy system?(00:18:43) – Is AI influencing how doctors prescribe medications?(00:19:54) – What role does the pharmacist plays in the current system? (00:21:18) – Do pharmacists have any ability to intervene or help patients navigate the formulary, or do they just dispense whatever is prescribe?(00:23:30) – What is prior authorization, and is it driven by clinical or financial outcomes?(00:27:36) – What are the different drug tiers and what qualifies a drug for each tier?(00:28:48) – What qualifies as a specialty drug?(00:30:20) – What is the difference is between prior authorization and step therapy?(00:31:40) – What role do generics in the current pharm landscape?(00:40:16) – Step therapy and biosimilars: how they each work(00:42:38) – Where does mail order fit into the pharmacy system?(00:48:00) – Rebates: the complicated and confusing system of paying for drugs(00:56:21) – Emerging PBMs and when it makes sense for clients to switch(00:59:33) – How can employers vet new-model PBMs when traditional rebate-heavy models look better on a spreadsheet?(01:02:59) – Closing thoughts from Matt Jarvis

With hospitals facing increasing drug company restrictions on access to 340B savings and other challenges, some might be considering opening their own retail pharmacies to serve their patients. We speak with Sherstin Willyerd, director of pharmacy operations at Montgomery County Memorial Hospital in Iowa, to learn about how her hospital went this route and what others want to consider before doing the same. Buying Existing Pharmacies Can Be a Solution Willyerd said her hospital was able to purchase two independent pharmacies whose owners were retiring, providing an existing dispensing infrastructure and patient base from which to start. While the hospital still has some contract pharmacy partnerships, the in-house locations can serve patients and generate 340B savings that are less prone to drugmaker restrictions.A Retail Pharmacy Can Give Better Insight into Patient StrugglesOperating a retail pharmacy allowed Willyerd's hospital to see more clearly which patients were struggling with prescription drug costs and medication adherence and to provide more assistance to them. She noted that capturing more 340B savings makes it easier to pass along more discounts to patients who otherwise would not be able to afford their drugs.An Independent Insurance Plan Means Even More AssistanceMontgomery County Memorial Hospital also partnered with a pharmacy benefit manager (PBM) to create a primary and secondary prescription drug insurance plan that it offers to certain patients with low incomes and hospital employees. Willyerd noted that this plan can mean hundreds of dollars in savings per month for uninsured patients and those whose coverage comes with high cost sharing.Resources:HRSA Releases 340B Purchase Data for 2025

A federal judge tosses a DOJ suit seeking Kentucky voters' sensitive personal data, Congressman Comer pushes for a bill to hold PBMs accountable, and a group looks to increase Louisville's accessible housing supply.

On today’s edition of The Scott Jennings Show, Scott examines the Secret Service briefing on the White House Correspondents’ Dinner, renewed scrutiny of ActBlue, and the key votes facing Congress this week. Scott also takes a look at Rep. Brandon Gill’s exchanges with the Left during recent congressional hearings and the political implications of the closely watched House race in Colorado’s 8th Congressional District. Rep. Tom McClintock joined the show to discuss his House floor speech contrasting freedom and socialism, as well as the broader debate surrounding New York City Mayor Zohran Mamdani’s policy agenda. Later, Rep. James Comer provided an update on pharmacy benefit manager (PBM) reform and his recent Oval Office visit, while Adam Gelb discussed the latest approaches to criminal justice reform and public safety policy. https://www.duke-energy.com/poweringamerica See omnystudio.com/listener for privacy information.

What does it take to move from fixing one broken corner of healthcare to reimagining the whole thing? On this episode of Astonishing Healthcare, host Justin Venneri sits down with two of his favorite guests together for the first time: Judi Health's CEO, AJ Loiacono, and Chief Commercial Officer, Kristin Begley, PharmD.The catalyst for this special episode is the company's rebrand, the evolution from Capital Rx, the transparent PBM that built Judi®, into Judi Health, a unified health technology company. AJ and Kristin explain why the "Rx" designation remains a core piece of the company's identity but no longer fully reflects the organization's evolving mission. They also describe the difference between "little T" transparency and the real thing, why incentive alignment matters so much, and what it took to build the first platform to process medical, pharmacy, dental, and vision claims on one system. They also express gratitude to the team and share bold predictions for where health benefits go next.Key TakeawaysThe rebrand reflects an expanded mission, not a new one. Capital Rx launched as a transparent PBM, with "Rx" signaling its focus on pharmacy. Over eight years, the company broadened its administrative capabilities, including medical claims processing, and much more - all powered by Judi. Thus, the primary brand: Judi Health, with services harmonized as Judi Rx (pharmacy), Judi Care (medical administration, TPA, navigation), and Judi Cloud (platform licensing for health plans and TPAs).There's a real difference between "little T" transparency and true transparency. AJ argues that true transparency means an auditable workflow: full disclosure of all compensation, proof that every customer receives the same pricing and benefit, and no hidden earnings. He calls out the "little H" holding company trick and explains why alignment yields better outcomes for plans and their members.‍Nobody had built unified claims processing before. AJ recalls initial skepticism around unified claims. His response: "If Netflix had kept mailing DVDs, we wouldn't be talking about Netflix." To date, no other organization has built a unified claims processing platform. Judi is the exception.Unified claims processing will become the standard. Once employers realize they have options, markets shift quickly. AJ, who predicted the rise of transparent PBMs, makes a new call: unified claims will be the industry norm.Related ContentJudi Health™ Announces Capital Rx is Now Judi Rx™, Launches Judi Care™ and Judi Cloud™ to Power the Next Era of Health Benefits Administration and Patient CareAH100 - The End of the Age of Confusion, It's Time for Acceptance, with AJ LoiaconoAH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmDWhat is a Core Administrative Processing System (CAPS) in Healthcare Payer Operations?AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya LomsadzeFor more information about this episode, please visit Judi Health Insights.

Cash-Pay Generic Drugs Are a Functioning Market in Healthcare, and Policymakers Could Break It. Episode 520. Cash-pay generic drugs are one of the few corners of US healthcare where a real, functioning market already exists — which is why Stacey Richter argues policymakers need to tread carefully when trying to "fix" drug affordability. In this solo episode, Stacey explains why cash generic prices can run as low as $1 a prescription, then plays clips from four past guests — Ge Bai, PhD, CPA; Bryce Platt, PharmD; Benjamin Jolley, PharmD; and Luke Slindee, PharmD — showing how inserting a PBM extracts $41 out of every $100 spent, leaving patients paying more for the "privilege" of using their insurance. WHAT YOU'LL LEARN ✅ Why cash-pay generic drugs are one of the few genuinely functioning markets left in US healthcare, with multisource manufacturer competition keeping prices as low as $1 to $18 per prescription ✅ Why using insurance/PBM coverage makes the 20 most prescribed generics more expensive 43% of the time overall, and up to 79% of the time in the deductible phase, per Ge Bai, PhD, CPA's research in Annals of Internal Medicine ✅ How PBMs extract $41 out of every $100 spent on generic drugs that cost roughly 47 cents to manufacture, largely through the administrative overhead of risk pooling ✅ How Most Favored Nation "lesser of" clauses in PBM-pharmacy contracts punish pharmacies for lowering their cash prices, and why Luke Slindee, PharmD, argues removing that single clause could unlock a more robust cash-pay market without pulling generics from insurance entirely ✅ Why generic drug adoption has slowed from about one month to six months to reach peak uptake, which Bryce Platt, PharmD, ties to PBM formulary control rather than reduced competition or prescriber resistance ✅ Four policy ideas Stacey floats for keeping generics affordable without wrecking the underlying market: eliminating MFN clauses, funded wallets or prepaid cards, pre-funded cash-pay pharmacy relationships, and removing generics from PBM adjudication entirely WHY THIS MATTERS Generic drugs are one of the only truly functioning markets left in US healthcare, and cash prices are already low because of it. But policymakers trying to make medications more affordable often reach for the same lever — routing everything through insurance/PBM adjudication — which the data shows frequently raises what patients pay while handing PBMs a 41-cent cut of every dollar spent. As Stacey puts it, "you have to be really careful what levers you push because you can't see what they're attached to," and the wrong fix could break the one part of healthcare that's actually working. MENTIONED IN THIS EPISODE EP444 with Ann Kempski: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP420 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP517 with Stacey: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Patrick Moore EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps === LINKS ===

Integrative Care Impact and the Expanding Role of the Pharmacist | TWIRx Today's episode of This Week in Pharmacy explores two major opportunities shaping the future of the profession: the growth of holistic and integrative pharmacy services inside community pharmacies, and the expanding demand for pharmacists across the business, insurance, and PBM sectors. In our first segment, Todd Eury welcomes special guests Robert Kress, RPh, and Dr. Bianca Bradshaw, PharmD, owner of Elmore Pharmacy in Red Bluff, California. Together, they discuss the tremendous opportunity for independent pharmacies to build holistic and integrative health departments that respond to growing consumer demand for natural products, supplements, wellness solutions, and personalized care. Dr. Bianca Bradshaw, PharmD https://www.linkedin.com/in/bianca-bradshaw-141092205/ Patients are increasingly seeking more natural approaches to health, but they still need trusted clinical guidance. Community pharmacists are uniquely positioned to help patients evaluate products, avoid harmful interactions, understand evidence, and develop safer, more effective wellness plans. This conversation explores how pharmacies can create new service lines, improve patient relationships, and establish sustainable revenue opportunities through integrative care. In our second segment, Dr. Bonnie Hui-Callahan, PharmD, returns to the show to discuss career opportunities for pharmacists within Judi Health and Capital Rx, as well as the broader business and insurance side of pharmacy. Dr. Bonnie Hui-Callahan, PharmD https://www.linkedin.com/in/bonnie-hui-callahan/ As PBMs continue to evolve, new-generation models are creating demand for pharmacists who understand clinical care, benefits, formulary strategy, patient access, data, and healthcare economics. Bonnie shares why pharmacists will remain essential as PBMs transform and why the profession should look beyond traditional dispensing and clinical practice roles when considering future career paths. Today's episode is sponsored by Independent Pharmacy Cooperative and SuiteRx. Listen to This Week in Pharmacy on the Pharmacy Podcast Network.

THIS WEEK IN PHARMACY PBM Truth, Cash-Based Pharmacy, and Psychedelics in Medicine Presented by SuiteRx Pharmacy Software Technologies Learn more at SuiteRx.com Episode Overview On this episode of This Week in Pharmacy, Todd Eury brings together two timely conversations focused on pharmacy transformation, advocacy, clinical education, and the future role of pharmacists in healthcare. First, Todd welcomes Brad Hart, owner of Forest Park Pharmacy, a cash-based independent pharmacy model challenging the traditional reimbursement structure many pharmacies operate under. Brad has become a powerful advocate for pharmacy transparency, using TikTok and social media to expose current PBM practices, share data, and speak directly to patients, pharmacy owners, and policymakers about the realities facing independent pharmacies. Brad's message is clear: patients deserve transparency, pharmacy owners deserve fair treatment, and the profession needs more voices willing to educate the public with facts and truth. In the second half of the episode, Todd is joined by Dr. Colby Burns and Dr. Andy Krut from the Psychedelic Pharmacists Association. This discussion helps set the groundwork for understanding psychedelics in medicine, the evolving role of pharmacists in psychedelic education, and the clinical potential of psychotropic therapies historically limited by regulation, stigma, and lack of provider education. As interest in psychedelic-assisted care grows, pharmacists must be part of the conversation. Dr. Burns and Dr. Krut explain why pharmacist education, medication safety, and clinical understanding are essential as healthcare explores emerging approaches to mental health, trauma, pain, and complex patient care. Featured Guests Brad Hart Owner, Forest Park Pharmacy Dr. Colby Burns Psychedelic Pharmacists Association Dr. Andy Krut Psychedelic Pharmacists Association Sponsored By This episode of This Week in Pharmacy is brought to you by SuiteRx Pharmacy Software Technologies. SuiteRx provides pharmacy software solutions designed to support independent pharmacies, improve workflow, enhance patient care, and help pharmacy teams operate more efficiently in today's demanding healthcare environment. Learn more at SuiteRx.com.

Your health plan might be robbing you blind. The fun part? You may be paying someone to let it happen. Healthcare benefits are one of the biggest expenses for small business owners, and most employers are stuck playing a game where the rules are hidden, the prices move, and somehow the bill always gets worse. In this episode of The Liquid Lunch Project, hosts Matthew R. Meehan and Luigi Rosabianca sit down with Donovan Ryckis, CEO of Ethos Benefits, to rip the lid off employer-sponsored healthcare. Donovan breaks down why insurance costs keep rising, how brokers can create conflicts of interest, why pharmacy benefit managers deserve a long side-eye, and how small businesses can start asking much better questions before renewal season punches them in the face.  

The 401-Level Financial Motive Behind Prior Auths and Pharma Rebate Contracting Imagine a cheaper, generic, or even clinically better drug that somehow ends up not on formulary at all, or stuck behind step edits and prior authorizations with a higher copay than the pricier brand sitting right next to it. In this solo episode, host Stacey Richter breaks down exactly how that happens, walking through a case study she calls Brand Number 2 versus the formulary's reigning Brand Darling to show how PBM and GPO rebate economics, not clinical need, often decide which drugs patients can access easily and which ones get thrown up against a wall of red tape. This is Episode 517 (EP517) of Relentless Health Value. WHAT YOU'LL LEARN ✅ How a high-volume Brand Darling generating billions in sales and huge aggregate rebates can keep a cheaper, generic, or more effective Brand Number 2 stuck on a nonpreferred tier, behind step edits and prior authorizations, regardless of price or efficacy ✅ Why a structural rebate cliff makes it nearly impossible for a new entrant to unseat an established Brand Darling on formulary, even if that new entrant offers a 99 percent rebate ✅ How rebate dollars a PBM or GPO wants to keep can be relabeled as a data fee, a service fee, or an admin fee, a dynamic also flagged by benefits consultant Robyn Tikia, letting a PBM still claim it passes along 100 percent of rebates ✅ Why a prior authorization is often used as a financial negotiating lever against a manufacturer's rebate offer rather than a clinical determination of whether a patient needs the drug ✅ How regulation such as the Inflation Reduction Act is compressing list prices and collapsing the rebate spread that the traditional contracting math depends on ✅ How GoodRx runs a reverse auction among PBMs to surface its advertised cash price, making coupon sites effectively a sales channel for the same PBMs that lock manufacturers into exclusive formulary contracts WHY THIS MATTERS As Stacey Richter lays it out, a PBM with a fiduciary duty to its shareholders has every financial incentive to double down on a high-volume Brand Darling and freeze out a cheaper or better Brand Number 2 with step edits and prior auths, whether or not that serves the patient stuck in the middle. As regulation compresses list prices and rebate spreads get less stable, more pharma manufacturers are deciding it is worth giving up access to large blocks of insured lives in order to control their own price directly through cash pay, patient assistance programs, or their own copay cards. It is not a clean alternative, since cash pay still runs through PBM-linked coupon platforms like GoodRx, but for some brands it is starting to look like the more controllable bet. === LINKS ===

Most people think healthcare is broken by accident.Mark Cuban says it isn't.In part two of our conversation, he explains the hidden companies who really control healthcare, where AI is headed, and the biggest opportunities most people are missing.He also shares the advice he gives young people, the three “superpowers” he believes matter more than talent, network, or money, and the one question he thinks everyone should ask themselves.

Only roughly 50% of new GLP-1 prescriptions were getting approved for coverage in 2023. From a plan sponsor's seat, that looks like pharmacy trend spiking 9%, 12%, even 20% year over year. From a pharma manufacturer's seat, it's half their prescriptions not getting filled. Same market, opposite problems — and that's exactly the lens this episode flips on. In this episode, Stacey Richter speaks with Ophelia Johnson, who built new business channels for a pharmaceutical manufacturer that created the GLP-1 boom and has since launched a consulting practice at e-fi.works, about how cash pay models work from the inside — coupon platforms, telehealth channels, white label pharmacy models, and employer carve-outs — and where the new fees are hiding. WHAT YOU'LL LEARN ✅ How the Inflation Reduction Act, PBM legal scrutiny, drug shortages, and the compounding bypass converged with ~50% GLP-1 prior auth denial rates in 2023 to push pharma into building cash pay channels that cut the PBM out entirely ✅ How the savings coupon model works: manufacturer buys the patient down to a flat transparent cash price via platforms like GoodRx, pays a fixed per-script fee instead of a PBM rebate, and the coupon platform makes the pharmacy whole — transparent math, no black box ✅ How the telehealth channel and white label pharmacy models extend the distribution chain beyond retail — and why shipping costs, credit card fees, dispensing fees, and new supply chain partners create gross-to-net and revenue leakage risk for manufacturers not built for it ✅ Why "direct to employer" is a misnomer: PBM contracts prohibit pharma from selling directly to self-insured employers, so third-party transparent administrators have emerged — but plan sponsors need to run the math first, given ERISA complications and PBM contract leverage ✅ How PBMs are now charging fees for hub-like patient support services to manage the exact prior auth complexity they created — a Whack-a-Mole shift of profitability that everyone needs to map before signing anything ✅ Ophelia's three-part practical advice: map the full patient journey and all ecosystem player incentives before building any new model (pharma); treat affordability as a clinical risk factor (clinicians); demand auditable medication abandonment data rather than settling for rebate yield metrics (plan sponsors) WHY THIS MATTERS If collaboration is the next innovation, everyone has to understand the incentives of every player in the ecosystem — not just their own. The same 50% of unfilled GLP-1 prescriptions that looks like runaway pharmacy trend from a plan sponsor's seat looks, from a manufacturer's seat, like half their market going dark — and both sides are making moves that affect each other. Understanding those moves, where fees are being layered on, and when fair profit tips into what Stacey calls profiteering is what this episode maps. TUNE IN NEXT WEEK Next week is the 401-level companion to this one — Stacey goes solo on the PBM and GPO contracting mechanics behind why cash pay became a thing, and why cheaper or better drugs can inexplicably end up off formulary or buried under prior auth. === LINKS ===