Podcasts about pbms

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

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 ===

Axios reported that Walmart raised its outlook while saying drug price declines pressured pharmacy results. Pharmacy margins are being squeezed by reimbursement terms set by PBMs, generic drug deflation, and the 2024 shift of pharmacy DIR fees to the point of sale. CVS Health and Walgreens Boots Alliance have cited similar headwinds, while Amazon Pharmacy, Mark Cuban Cost Plus Drug Company, and GoodRx are reshaping price transparency and consumer behavior. The Inflation Reduction Act will add Medicare drug price negotiations in 2026 and a $2,000 Part D out-of-pocket cap in 2025, which could shift volumes and reimbursement flows. Rising demand for GLP-1 drugs adds inventory and authorization complexity without guaranteed margin lift. Walmart's 2024 exit from its health clinics highlights how reimbursement pressures influence strategy, pushing focus back to core pharmacy services and OTC products.Learn more on this news by visiting us at: https://greyjournal.net/news/ Hosted on Acast. See acast.com/privacy for more information.

Health care feels personal until you try to navigate it and realize how many parts are designed to be confusing. From the Mackinac Policy Conference, we sit down with former Michigan U.S. Senator Debbie Stabenow for a fast, candid conversation about what's working, what's breaking, and what Michigan communities need next.We start with the pressure points she's most concerned about right now: mental health access, Medicaid cuts, and affordability. Stabenow explains why community behavioral health clinics with 24-hour access matter, not just for patients in crisis, but for families, hospitals, and communities trying to keep people out of emergency rooms and jails. We also talk about rural health care in northern Michigan, where hospitals are often the biggest employer and the backbone of local access, yet many are being forced to cut beds, reduce services, or stop delivering babies.Then we zoom out to the national policy fights. Stabenow reflects on the Affordable Care Act, what she would keep, and what she would change, including her push for a public Medicare option to drive real competition. She shares a stark reminder of why “essential health benefits” matter by revisiting the days when pregnancy could be treated like a pre-existing condition and prenatal coverage was far from guaranteed. We close on prescription drug prices, Medicare Part D, and the long-running impact of blocking Medicare from negotiating prices, plus how PBMs add yet another layer of complexity.If you care about Michigan health care, rural hospitals, mental health policy, the Affordable Care Act, Medicaid, and prescription drug costs, this one's for you. Subscribe, share this conversation with a friend, and leave a review so more people can find The Common Bridge.Support the showEngage the conversation on Substack at The Common Bridge!

Katy Talento ran healthcare at the White House Domestic Policy Council and helped push through the price transparency executive order. Now she runs health plans for a living, including for the convent where she once lived as a nun.She spends this episode on why a post-network world keeps hitting the same wall: the three-way contracts between carrier, TPA, and provider that make the network Plan A by force. She explains why she thinks those provisions violate the Sherman Act, what DOJ has started doing about it, and why the workarounds employers use today amount to an underground railroad rather than a functioning market.We also cover the 2026 CAA and the DOL rule that together make PBMs fiduciaries and may do the same to TPAs, her four-part "school choice for healthcare" plan to scale cash pay nationally, and the AI upcoding wave she thinks is breaking stop-loss actuarial models right now.If you've ever wondered why the obvious fix isn't available to you, this is the episode. Tune in."Nobody in the entire town understands employer-sponsored care. All the oxygen is on 20 million people on the ACA. But 180 million people over here, we're not doing any policy for." - Katy TalentoThank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro(00:01:05) From Epidemiologist to Capitol Hill(00:05:37) The Nun Years and Her First Client(00:10:50) Inside the Price Transparency Executive Order(00:16:58) Why Washington Ignores 180 Million People(00:20:33) What Transparency Data Can Actually Do Now(00:25:55) The Plantation Contracts(00:29:01) DOJ, the Sherman Act, and Anti-Competitive Provisions(00:33:04) The CAA and the DOL Rule That Reset Fiduciary Duty(00:39:16) Why the Big Three PBM Model Is Now Illegal(00:46:53) RBP's Access Problem: The Nuns at NYU Langone(00:54:54) The Holy Grail: One Cash Price(00:57:46) School Choice for Healthcare(01:13:43) AI Upcoding and Why Stop-Loss Models Broke(01:21:15) Closing Thoughts: Tell Your StoryKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Katy Talento ran healthcare at the White House Domestic Policy Council and helped push through the price transparency executive order. Now she runs health plans for a living, including for the convent where she once lived as a nun.She spends this episode on why a post-network world keeps hitting the same wall: the three-way contracts between carrier, TPA, and provider that make the network Plan A by force. She explains why she thinks those provisions violate the Sherman Act, what DOJ has started doing about it, and why the workarounds employers use today amount to an underground railroad rather than a functioning market.We also cover the 2026 CAA and the DOL rule that together make PBMs fiduciaries and may do the same to TPAs, her four-part "school choice for healthcare" plan to scale cash pay nationally, and the AI upcoding wave she thinks is breaking stop-loss actuarial models right now.If you've ever wondered why the obvious fix isn't available to you, this is the episode. Tune in."Nobody in the entire town understands employer-sponsored care. All the oxygen is on 20 million people on the ACA. But 180 million people over here, we're not doing any policy for." - Katy TalentoThank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro(00:01:05) From Epidemiologist to Capitol Hill(00:05:37) The Nun Years and Her First Client(00:10:50) Inside the Price Transparency Executive Order(00:16:58) Why Washington Ignores 180 Million People(00:20:33) What Transparency Data Can Actually Do Now(00:25:55) The Plantation Contracts(00:29:01) DOJ, the Sherman Act, and Anti-Competitive Provisions(00:33:04) The CAA and the DOL Rule That Reset Fiduciary Duty(00:39:16) Why the Big Three PBM Model Is Now Illegal(00:46:53) RBP's Access Problem: The Nuns at NYU Langone(00:54:54) The Holy Grail: One Cash Price(00:57:46) School Choice for Healthcare(01:13:43) AI Upcoding and Why Stop-Loss Models Broke(01:21:15) Closing Thoughts: Tell Your StoryKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

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.

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.

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.

In this episode of The Benefits Brief, host David Saltzman sits down with Zac Hanson, vice president of growth at RxPreferred, to discuss why pharmacy benefits remain one of the least transparent areas of healthcare spending—and what benefits advisors can do about it. Zac explains the factors driving pharmacy costs, including specialty medications and plan design, while exploring the importance of data transparency, proactive pharmacy management, and asking the right questions of PBMs. He also shares practical strategies to help advisors better understand their clients' pharmacy spend and make more informed recommendations that improve outcomes and control costs.

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

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.

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.

GLP-1 therapies are transforming pharmacy benefits, and Express Scripts is leading the way. Harold Carter, PharmD, SVP of Trade Relations, joins host Eric Glazer to discuss how one of the nation's largest PBMs is navigating this disruptive moment in healthcare. Harold shares how Express Scripts is: Capping costs of GLP-1 therapies to expand patient access while keeping plan spending predictable. Redesigning funding models to strike a balance between affordability, predictability, and outcomes. Leveraging digital tools and AI to reduce friction in the member experience and support long-term adherence. Rethinking formularies not just as cost-control tools but as part of a broader population health and behavioral change ecosystem. You'll also hear his forward-looking perspective on how PBMs will evolve over the next three to five years, and the key questions health plans and employers should be asking today to prepare for the future of pharmacy benefits. About Dr. Harold Carter:   Harold Carter, PharmD, is responsible for leading all interactions and contracting with pharmaceutical manufacturers and oversees strategy and management of Express Scripts' drug formularies, data & insights, client underwriting, and product strategy and development. In his nearly 14 years with the organization, Harold has held numerous leadership roles oriented around critical efforts to lower the cost of prescription drugs and ensuring medication access for Express Scripts clients and members. Harold's previous responsibilities include oversight of the organization's medical pharma contracting and drug procurement teams, as well as leading the strategy, development and execution of Express Scripts' wholesale market, value-based solutions and generic strategy, and development of Express Scripts' advanced utilization management solutions.  In addition to his work at Express Scripts, Harold serves on numerous boards including LifeWise Stl Board of Directors, St. Louis University High School Board of Trustees and IVI Board of Directors. Harold earned his doctorate in pharmacy from St. Louis College of Pharmacy.   Partner with Bright Spots Ventures: If you are interested in speaking with the Bright Spots Ventures team to brainstorm how we can help you grow your business via content and relationships, email hkrish@brightspotsventures.com  About Bright Spots Ventures: Bright Spots Ventures is a healthcare strategy and engagement company that creates content, communities, and connections to accelerate innovation. We help healthcare leaders discover what's working, and how to scale it. By bringing together health plan, hospital, and solution leaders, we facilitate the exchange of ideas that lead to measurable impact. Through our podcast, executive councils, private events, and go-to-market strategy work, we surface and amplify the "bright spots" in healthcare, proven innovations others can learn from and replicate. At our core, we exist to create trusted relationships that make real progress possible. Visit our website at www.brightspotsinhealthcare.com.  

"The most unused cash in the country right now is the money you're wasting on healthcare... If you save a million dollars a year, that's $20 million in market cap."Is your company treating its healthcare spend like a business strategy, or are you just writing a blank check to the major insurance carriers every year?In this episode, I was (finally) joined by Mark Cuban, Ann Lewandowski, and Matt Miron. After answering how he would approach healthcare for a hypothetical company on Shark Tank, Mark broke down his exact playbook for mid-market employers: why you should fire traditional networks, the massive ROI of hiring an internal "Healthcare CFO" to negotiate single-case agreements, and why "carve-out" is the most important phrase for your benefit strategy this year. Together, we also discussed the dark side of healthcare economics, including the exorbitant spread pricing of PBMs and distributors, how to use AI (like Claude or ChatGPT) to find the hidden "gotchas" in your ASO contracts, and the terrifying legal liabilities CEOs face when their carriers deny life-saving treatments.This one has been in the works for years, and I hope it doesn't disappoint. Tune in!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Introductions: Mark Cuban, Ann Lewandowski, and Matt Miron (00:01:08) Mark Cuban's Healthcare Playbook for Shark Tank Companies (00:05:54) Single Case Agreements and Hiring an Internal Healthcare CFO (00:10:08) Why the Keyword for 2026 is "Carve Out" (00:14:32) Fiduciary Duty and Waiving Employee Deductibles (00:20:52) Starting with Out-of-Network Negotiations (00:25:09) The No Surprises Act, IDR Arbitration, and Secret Payouts (00:29:12) Why Mark Started Cost Plus Drugs (and Cost Plus Wellness)(00:32:10) How Distributors and PBMs Inflate Drug Prices (00:36:49) Using AI (Claude/ChatGPT) to Audit Your Carrier Contracts (00:37:52) The 340B Scam and Fiduciary Lawsuits (00:44:27) Increasing Enterprise Value: Why Healthcare Savings = Market Cap (00:47:46) CEO Liability for Life-Threatening Claim Denials (00:50:37) The Perverse Economics of Prior Authorizations and Appeals (00:52:59) Final Takeaways: Watch Your Money and Carve OutKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"The most unused cash in the country right now is the money you're wasting on healthcare... If you save a million dollars a year, that's $20 million in market cap."Is your company treating its healthcare spend like a business strategy, or are you just writing a blank check to the major insurance carriers every year?In this episode, I was (finally) joined by Mark Cuban, Ann Lewandowski, and Matt Miron. After answering how he would approach healthcare for a hypothetical company on Shark Tank, Mark broke down his exact playbook for mid-market employers: why you should fire traditional networks, the massive ROI of hiring an internal "Healthcare CFO" to negotiate single-case agreements, and why "carve-out" is the most important phrase for your benefit strategy this year. Together, we also discussed the dark side of healthcare economics, including the exorbitant spread pricing of PBMs and distributors, how to use AI (like Claude or ChatGPT) to find the hidden "gotchas" in your ASO contracts, and the terrifying legal liabilities CEOs face when their carriers deny life-saving treatments.This one has been in the works for years, and I hope it doesn't disappoint. Tune in!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Introductions: Mark Cuban, Ann Lewandowski, and Matt Miron (00:01:08) Mark Cuban's Healthcare Playbook for Shark Tank Companies (00:05:54) Single Case Agreements and Hiring an Internal Healthcare CFO (00:10:08) Why the Keyword for 2026 is "Carve Out" (00:14:32) Fiduciary Duty and Waiving Employee Deductibles (00:20:52) Starting with Out-of-Network Negotiations (00:25:09) The No Surprises Act, IDR Arbitration, and Secret Payouts (00:29:12) Why Mark Started Cost Plus Drugs (and Cost Plus Wellness)(00:32:10) How Distributors and PBMs Inflate Drug Prices (00:36:49) Using AI (Claude/ChatGPT) to Audit Your Carrier Contracts (00:37:52) The 340B Scam and Fiduciary Lawsuits (00:44:27) Increasing Enterprise Value: Why Healthcare Savings = Market Cap (00:47:46) CEO Liability for Life-Threatening Claim Denials (00:50:37) The Perverse Economics of Prior Authorizations and Appeals (00:52:59) Final Takeaways: Watch Your Money and Carve OutKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

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 Americans think they live in a free market.But if that's true, why do we keep ending up with fewer airlines, fewer hospitals, fewer pharmacies, fewer banks, fewer food processors, and fewer choices?In this episode of Common Sense with Chad Law, we take a hard look at the forgotten conservative history of antitrust, trustbusting, and competition. From Theodore Roosevelt and Standard Oil to Reagan and AT&T, we explore why conservatives once saw concentrated corporate power as a threat—and why that conversation disappeared.We'll break down how government intervention, regulation, consolidation, lobbying, and market concentration created an economy where giant corporations increasingly dominate healthcare, technology, food, airlines, banking, and communications.This isn't an argument against capitalism.It's an argument for competition.Because capitalism isn't giant corporations.Capitalism is the freedom to take your business somewhere else.Topics include:• Standard Oil• AT&T and the Reagan breakup• Google's dominance• Healthcare consolidation• PBMs and prescription drug costs• Food industry concentration• Defense contractor consolidation• Government regulation and barriers to entry• Competition vs competitors• Why your paycheck doesn't go as far as it used toIf you enjoy thoughtful conversations about economics, politics, public policy, and common sense solutions, subscribe and share the show.00:00 The Illusion of Monopolies00:27 The Burden of Regulation06:20 The Myth of Free Markets11:48 The Conservative Legacy of Antitrust20:00 Lessons from History: Standard Oil and AT&T26:45 The Pressure of Competition in a Free Market28:27 The Role of Conservatives in Trustbusting28:52 Government Intervention and Market Consequences31:01 The Cycle of Government Fixes and Market Distortion32:53 The Impact of Regulations on Small Businesses36:17 The Creation of Monopolies through Government Meddling38:07 The Loop of Market Concentration and Political Influence41:12 The Healthcare Market and Its Concentration46:05 The Modern Monopoly: Google and Its Influence51:42 Concentration in the Food Industry57:38 The Squeeze on Farmers and Consumers59:34 The Velvet Rope of the Food Market01:00:11 The Role of Middlemen in Healthcare01:01:33 The Airline Industry's Struggles01:03:25 Concentration of Power Across Industries01:04:10 The Confusion of Antitrust Principles01:07:46 The Shift from Building to Bargaining01:11:12 The Path to Restoring Competition01:12:19 Lessons from History: The Breakup of Ma Bell01:14:09 The Call to Action for Competition

In this episode of Healthcare Happy Hour, host David Saltzman sits down with Jim Jusko, chief strategy officer at Excel Health Plans, to explore how hospital systems, provider networks, and pharmacy benefit managers (PBMs) shape healthcare costs, competition, and consumer choice behind the scenes. Jim discusses the impact of consolidation, limited transparency, and anti-competitive practices on employers and consumers, while highlighting policy and market-based solutions that could improve affordability, increase competition, and create a more transparent healthcare system. He also shares his vision for a healthcare marketplace that better aligns incentives for employers, providers, and patients.

In this episode, we are joined by Chris Hamilton, Partner and Employee Benefits Practice Leader at Hotchkiss Insurance, an independent insurance agency based in Texas. With nearly two decades of experience in corporate finance and employee benefits, Chris helps employers navigate the complexities of the healthcare system, reduce costs, and gain greater control over their health plans by moving beyond traditional insurance models. In addition to his work at Hotchkiss Insurance, Chris is the founder of Benefits Insider, an educational platform dedicated to helping employers understand how healthcare financing really works. Through practical case studies, industry analysis, and real-world examples, he empowers business leaders to make more informed decisions about employee benefits and healthcare spending. Recognized as the 2025 BenefitsPro Advisor of the Year, Chris has become a leading voice on healthcare transparency, employer-sponsored health plans, and cost-containment strategies. He regularly contributes to podcasts, conferences, and educational content designed to simplify one of the most misunderstood areas of business. This conversation explores: How Chris got started in the healthcare and employee benefits industry The unintended consequences of the Affordable Care Act on employers and healthcare  The incentives that drive insurance companies, pharmacy benefit managers (PBMs), and other healthcare stakeholders Alternative approaches to controlling healthcare costs  Why are healthcare costs continuing to rise, and what can employers do to take back control of their benefits strategy? Tune in to hear Chris's practical insights into the healthcare system and how businesses can create more efficient, cost-effective plans for their employees. Connect with Chris: Personal Website Hotchkiss Insurance LinkedIn Youtube Tiktok

Let's talk PBM's.  What even is a P-B-M? Pharmacy benefit managers have been around since the 1960's, although back then, they were basically claims processors. Things changed in the 80's and 90's following the first iteration of ERISA when employers saw PBMs as potential cost containment strategies. The industry continued to explode until 2007 when CVS acquired Caremark, and now the market is really consolidated into just three major players. Why does this matter? Well, PBMs control just about everything drug-related in the US these days, and that includes the cost. Given that we have not seen the promised drop in drug prices, Americans and employers are still bearing the burden of this bloated and broken system.  To unpack how this works and what folks are doing about it, we invited back Shawn Gremminger, the President and CEO of the National Alliance of Healthcare Purchaser Coalitions. His organization works with regional coalitions of employers to help them advance health policy, leverage their collective power, and drive market change.

THIS SPONSORED PODCAST EPISODE IS BROUGHT TO YOU BY CVS HEALTH.In this sponsored episode, James Margiotta, Chief Growth Officer at CVS Caremark, joins Health Affairs Publishing's Jessica Bylander to unpack the role of pharmacy benefit managers (PBMs), their impact on prescription drug costs, and the value PBMs bring to the health care system.James has nearly 35 years of experience driving innovation, operational excellence, and enterprise value across the healthcare system. In his current role, James leads the team responsible for partnering with clients to identify their unique needs and bringing forward strategic solutions to meet their objectives.Throughout his career at CVS Health, James has scaled businesses across CVS Caremark, CVS Accountable Care, Minute Clinic, Aetna, and CVS Pharmacy — each with its own challenges, cultures, and market dynamics.James and Jessica's conversation explores how PBMs help employers, health plans, governments, and unions manage rising prescription drug costs while balancing affordability, transparency, and member experience. James explains CVS Caremark's approach to controlling costs, dives into the growing demands for price transparency, and how artificial intelligence may transform pharmacy benefits and member navigation services.

THIS SPONSORED PODCAST EPISODE IS BROUGHT TO YOU BY CVS HEALTH.In this sponsored episode, James Margiotta, Chief Growth Officer at CVS Caremark, joins Health Affairs Publishing's Jessica Bylander to unpack the role of pharmacy benefit managers (PBMs), their impact on prescription drug costs, and the value PBMs bring to the health care system.James has nearly 35 years of experience driving innovation, operational excellence, and enterprise value across the healthcare system. In his current role, James leads the team responsible for partnering with clients to identify their unique needs and bringing forward strategic solutions to meet their objectives.Throughout his career at CVS Health, James has scaled businesses across CVS Caremark, CVS Accountable Care, Minute Clinic, Aetna, and CVS Pharmacy — each with its own challenges, cultures, and market dynamics.James and Jessica's conversation explores how PBMs help employers, health plans, governments, and unions manage rising prescription drug costs while balancing affordability, transparency, and member experience. James explains CVS Caremark's approach to controlling costs, dives into the growing demands for price transparency, and how artificial intelligence may transform pharmacy benefits and member navigation services.

In this episode of the PBM Reform Podcast, host Greg Reybold, Vice President and General Counsel at APCI, welcomes Josh Golden, Senior Vice President of Strategy at Judi Health and a nationally recognized voice in Pharmacy Benefit Manager reform. With more than 20 years of healthcare consulting experience, Golden brings deep expertise in vendor procurement, contract negotiation, plan design, and benefit strategy for large employers, government entities, and unions. Together, Reybold and Golden examine the financial models behind today's PBM industry and why true transparency remains so difficult for employers, plan sponsors, patients, and pharmacies. The conversation explores how current PBM arrangements often benefit the PBMs more than the employers paying for coverage or the patients relying on their prescription benefits. Golden explains why auditing PBM contracts, rebate structures, spread pricing, administrative fees, pharmacy networks, and formulary decisions is essential to understanding the real economics of prescription drug benefits. This episode also addresses a growing concern in healthcare: PBM steering behavior. Are patients being quietly pushed toward specific formularies, specific pharmacies, and restricted networks that operate like closed networks without being clearly disclosed? Reybold and Golden discuss how this behavior can limit patient choice, disadvantage independent pharmacies, and distort the stated goal of lowering drug costs. The discussion also tackles the role of federal reform efforts, including whether the Appropriations Act represents meaningful PBM accountability or whether it risks becoming another layer in the broader shell game surrounding PBM reform. Finally, the episode asks one of the most important questions in pharmacy policy today: should PBMs own pharmacies? If vertical integration is promoted as a way to lower drug costs, where is the proof — and who actually benefits? Transparency, Auditing, and the PBM Shell Game | PBM Reform

This time on Healthcare Now we've got a friendly face returning (by phone)! Dr Betsy Dovec is the brain behind The Surgical Institute Of Central Florida, she joins Larry and Doctor Mark from out on the scene in Winter Garden to talk with them about the world behind health care now! What's the latest about those weight-loss drugs? What do you need to know to keep yourself safe if you use them? More big lawsuits about billing, learn the math in play at some of the PBMs and insurance companies! Rural care challenges and the ACA are just a couple of the subjects at hand! And what about burgers? See omnystudio.com/listener for privacy information.

This time on Healthcare Now we've got a friendly face returning (by phone)! Dr Betsy Dovec is the brain behind The Surgical Institute Of Central Florida, she joins Larry and Doctor Mark from out on the scene in Winter Garden to talk with them about the world behind health care now! What's the latest about those weight-loss drugs? What do you need to know to keep yourself safe if you use them? More big lawsuits about billing, learn the math in play at some of the PBMs and insurance companies! Rural care challenges and the ACA are just a couple of the subjects at hand! And what about burgers? See omnystudio.com/listener for privacy information.

So much for common ground… Buckle up because this week Jillian Michaels sits across from Sam Seder, host of The Majority Report, for a bare-knuckle debate on government waste, Iran, Israel, Russia, Ukraine, DOGE, USAID and more. Nothing was off-limits. If you wanted a polite, coordinated conversation, go somewhere else. This is a full-throated ideological fight. In this episode, they tear into: The Global Health & Foreign Aid Crisis: The dismantling of USAID is front and center — is America's withdrawal from international NGO funding a necessary correction or a catastrophic failure? The debate gets heated fast, with the "last-mile" operational collapse in Uganda and the human cost of overnight co-investment mandates laid bare. The Mamdani-Khomeini Comparison: The Iranian diaspora isn't staying quiet — and this is where things get truly combustible. Jillian comes in swinging, amplifying the voices of exiles who lived through the revolution and are drawing chilling parallels between Mamdani's ideological framework and the Ayatollah's early intellectual positioning and Sam gets outraged. The Iran Conflict & The Fog of War: A fierce legal and ethical battle erupts over the recent strikes in Iran. The tragic Minab school bombing, the possibility of flawed targeting intelligence, and the complex question of civilian protections when military assets are embedded in non-military infrastructure all get put under the microscope. Russia, Ukraine & the NATO Fault Line: With the war grinding into a new phase, they go head to head on whether Western alliance commitments are a stabilizing force or a provocation that made this conflict inevitable DOGE, PBMs, and Domestic Warfare: The heat turns inward to tackle domestic deregulation, the rising influence of the Department of Government Efficiency, and whether the new delinking and transparency rules under the TrumpRx framework are liberating healthcare or creating new corporate loopholes for PBMs to exploit. Two distinct worldviews. Absolute zero consensus. Who held their ground, and who got exposed? Stream the full, unfiltered debate now and drop your thoughts in the comments below. OneSkin: Get 15% off OneSkin with the code KEEPINGITREAL at https://www.oneskin.co/KEEPINGITREAL #oneskinpod Skims: Shop Everyday Cotton, and all of my favorite bras and underwear at http://www.skims.com/jillian #skimspartner Beam: Visit https://shopbeam.com/REAL and use code REAL to get our exclusive discount of up to 40% off. Learn more about your ad choices. Visit megaphone.fm/adchoices

The city of Des Moines is expecting a budget shortfall after Governor Kim Reynolds signed a property tax bill into law. Democratic candidate for governor Rob Sand says he would address PBMs. And who are the Republicans running to represent Iowa's Second Congressional District?

On today's episode of The Gist Healthcare Podcast: health systems join a new federal initiative aimed at streamlining prior authorizations, lawmakers revive legislation that would ban PBMs from owning retail pharmacies, and a judge clears the way for CVS Health to sell its long-term care pharmacy business. Hosted on Acast. See acast.com/privacy for more information.

Independent pharmacies in Rhode Island are making a call for pharmacy benefit manager reform, pointing to "predatory practices" such as price gouging and limiting access to medications. Local pharmacy owner have now launched a campaign seeking immediate relief from the Rhode Island General Assembly to protect independent pharmacies and customers from what they describe as harmful conduct by PBMs. Nicholas Shanos of Suburban Pharmacy joins Gene to discuss these issues.See omnystudio.com/listener for privacy information.

In 2008, Katy Talento walked away from Capitol Hill and into a Catholic convent. Within a year, she walked out. Within another decade, she sat inside the White House shaping health policy. Somewhere in between, she got labeled “infertile” after a single cycle of testing and spent years believing it.That label stuck. The pain that came before it never got investigated. Doctors offered birth control and moved on. No one asked why her body was struggling. No one followed the thread.Talento built her career inside the very systems she now critiques. She worked on federal health policy, global disease programs, and later advised the Trump administration on healthcare reform. She helped advance price transparency rules in a system where hospitals can still list 457 different prices for the same service.Then she left.Now she builds employer health plans that bypass insurers, PBMs, and traditional networks. Her approach replaces insurance contracts with direct payment, nurse navigators, and cost sharing models that promise simplicity but raise hard questions about risk and protection.This conversation sits in that tension.Talento describes a healthcare system shaped by layered incentives, where insurers, hospitals, and intermediaries profit from complexity. She argues that employers hold the leverage to disrupt it. The host pushes on what happens when patients fall outside those structures, when contracts disappear, and when community based models fail.The episode moves through infertility, misdiagnosis, insurance design, and the mechanics of employer sponsored care. It tracks how policy decisions made in Washington ripple into exam rooms, billing departments, and family lives.It also confronts a harder truth.Even insiders who understand the system can still get caught in it.RELATED LINKSAllBetter HealthKaty TalentoThem Before UsAn Arm and a LegRelentless Health ValueFEEDBACKLike this episode? Rate and review Out of Patients on your favorite podcast platform. For guest suggestions or sponsorship email podcasts@matthewzachary.comSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

**In this episode, I explain why rapid growth in a PBM-heavy pharmacy actually triggers serious cash flow problems, how the timing gap between paying your wholesaler and getting reimbursed by PBMs creates a financial squeeze, and what you can do to offset it.** **Show Notes:** 1. **Introduction** [0:00] 2. **Cash Flow Challenges in Pharmacies** [0:10] 3. **Impact of Rapid Growth on Cash Flow** [2:45] 4. **Strategies to Mitigate Cash Flow Issues** [3:54] 5. **Financial Consequences of Pharmacy Growth** [6:19] 6. **Controlling Your Pharmacy Cash Flow** [7:17] **Links mentioned in this episode:** Join our DiversifyRx Facebook Group for FREE: https://www.facebook.com/groups/diversifyrx/   ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network**

Welcome back to Last Month in Healthcare! This month, Spencer and Nathaniel sit down without a guest to unpack the biggest healthcare headlines and regulatory shifts from April 2026.From state-level crackdowns on PBMs to a surprising loophole that allows urban hospitals to siphon rural hospital aid, the guys dissect the policy changes and market moves that are actively reshaping the industry. They also discuss the affordability crisis driving a 26% surge in ACA Bronze plan enrollment, Amazon's aggressive new play into the GLP-1 and primary care market, and why CMS is finally (and officially) killing the fax machine by 2028.Plus, Spencer plays a game of "Blind Ranking," attempting to properly order the top 10 best practices and features of a modern self-funded health plan (including pass-through PBMs, cash-pay surgery networks, and pharmacogenomics) without knowing what's coming next.Thank you to this year's sponsor, Walk On Clinic!If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Chapters: (00:00:00) Intro & Sponsor Shoutout: Walk On Clinic (00:01:42) Bipartisan State Healthcare Regulations & PBM Oversight (00:04:40) ACA Shifts: The Rise of Bronze Plans & HSA Eligibility (00:08:38) The FTC's Vague New Healthcare Task Force (00:10:10) The Rural Hospital Aid Loophole Exploited by Urban Hospitals (00:11:27) Amazon Launches a $149/mo GLP-1 & Primary Care Program (00:15:18) CMS is Finally Ending the Fax Machine (Saving $781M) (00:16:48) Game: Blind Ranking the Best Self-Funded Plan Features (00:24:45) PSA: Watch Out for These Hidden Carrier Contract Clauses

In this episode, guest Antonio Ciaccia, president of consulting firm 3 Axis Advisors and founder/CEO of non-profit 46brooklyn Research, joins host Dan Karnuta for a discussion about U.S. drug pricing. The model is opaque because it runs on inflated list prices and hidden discounts created by government policy and industry incentives. Instead of competing on price, drug companies raise prices and offer rebates through intermediaries like pharmacy benefit managers (PBMs), who control which drugs are covered. This system weakens normal market forces and concentrates power in the middle of the supply chain. Karnuta is an associate professor in the Naveen Jindal School of Management's Organizations, Strategy and International Management Area as well as director of its Professional Program in Healthcare Management.

In this episode of the AI at Health series on The Beat Podcast, host Sandy Vance sits down with Venky Ananth, Executive Vice President and Head of Healthcare at Infosys, for a wide-ranging and energizing conversation about what it actually means for AI to transform healthcare at scale. Venky brings a refreshingly honest and structured perspective to a conversation that is often dominated by hype, breaking down why AI is fundamentally different from every other technology wave healthcare has been through, laying out the five areas where Infosys is seeing real traction with payers, providers, and PBMs right now, and sharing the story behind two exciting developments: the acquisition of Optimum Health IT and the Pacesetters podcast and executive leadership community. If you are a healthcare leader trying to figure out where to start or how to think about AI as a whole-enterprise challenge rather than a point solution, this episode is essential listening.  In this episode, they talk about: AI is not a point solution; it is a new operating system that will touch every function in every organization Healthcare is broken, fragmented, and frustrating, and AI is the first technology with the potential to fix all three at once Legacy modernization must come before AI adoption because you cannot layer intelligence on top of broken processes AI can now reverse engineer legacy systems that used to depend entirely on tribal knowledge The five pillars of AI transformation are strategy and engineering, legacy modernization, data, process reengineering, and physical AI Training AI on your own private data is the competitive wedge that separates leaders from followers Agents are the new team members, and organizations need to rethink how humans and agents orchestrate workflows together Infosys acquired Optimum Health IT, the number one-ranked Epic implementation partner according to KLAS, to deepen its provider capabilities Epic now covers an estimated 220 to 230 million distinct patients in the US and is growing internationally The Pacesetters podcast and annual executive gathering bring together CIOs, CTOs, academics, and analysts for candid, off-the-record dialogue about the future of healthcare A Little About Venky Ananth: Venky is a technology and transformation executive with deep experience leading a global business unit, scaling high-performance organizations, and delivering large-scale change through AI, cloud, and modern growth operating models. His career has focused on helping enterprises modernize core systems, improve operational efficiency, and unlock new growth through platform innovation and disciplined execution. He founded and scaled Infosys Helix, a cloud-native platform business that continues to shape payer and health platform modernization. In addition, he has led global teams across engineering, delivery, consulting, and product, giving him a broad view of strategy, technology, operations, and organizational scale. He operates at the intersection of technology, business model transformation, and leadership development, with a track record of strengthening enterprise performance and building organizations capable of sustained growth. Beyond his operating role, I host PaceSetters, a CXO leadership platform featuring conversations with leaders from healthcare, academia, private equity, and technology. 

On this special LIVE from HIMSS 2026 Gil is joined by two-time TEDx speaker Christina Madison, PharmD, FCCP, AAHIVP, the founder and CEO of The Public Health Pharmacist, for a candid, wide-ranging conversation about the profession's inflection point. From the chronic misdiagnosis of cardiovascular disease in women, to the existential threat posed by PBMs and automation, to the urgent fight for pharmacist provider status, Dr. Madison articulates a bold vision: community pharmacists aren't just pill dispensers, they are public health's most accessible, underutilized, and undercompensated front line. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

The Nurses Report on America Out Loud with Ashley Caputo, RN, FMP – This episode of The Nurses Report explores how Pharmacy Benefit Managers shape access to medications, often leading to delays and denials. It examines carve-outs, ERISA limits, and real patient impacts while highlighting the growing need for transparency, advocacy, and patient-centered decision-making in today's healthcare system...

Congratulations to Logan Eury and his new wife Emily, got married today, May 1, 2026!  This C.O. Bigelow Collab Introduces the 188-Year-Old Pharmacy to a New Generation Abbode is taking over the Carolyn Bessette-Kennedy-approved shop for a month-long pop-up. https://fashionista.com/2026/05/co-bigelow-abbode-pop-up-carolyn-bessette-impact  The article highlights how a pop-up and renewed interest in C.O. Bigelow has been fueled by the cultural resurgence of Carolyn Bessette-Kennedy's minimalist style, amplified by media and social buzz. This renewed attention has driven significant foot traffic and sales, showing how storytelling, nostalgia, and “quiet luxury” aesthetics can translate into real retail impact.   Q&A: Mayo Clinic leaders share strategies for managing high-cost drugs without breaking the bank | Asembia AXS26 Summit https://www.managedhealthcareexecutive.com/view/q-a-mayo-clinic-leaders-share-strategies-for-managing-high-cost-drugs-without-breaking-the-bank-asembia-axs26-summit Mayo Clinic leaders emphasize that managing high-cost drugs requires clear definitions, structured formulary review processes, and multidisciplinary collaboration to balance cost, access, and clinical value. They highlight the importance of evaluating safety, efficacy, financial impact, and site-of-care decisions together, while noting that non-340B systems face increasing pressure from rising costs and reimbursement constraints. Ultimately, success depends on stronger alignment between health systems, manufacturers, and payers to sustain access without compromising quality of care.  Where Gross-to-net Pressure Actually Lives After Launch Today's guest post comes from Cindy Baksh, Chief Product Officer at ConnectiveRx. https://www.drugchannels.net/2026/05/where-gross-to-net-pressure-actually.html The article explains that “gross-to-net pressure” isn't driven by a single factor, but by a combination of rebates, discounts, fees, and policy changes that continue to reshape how drug pricing actually works behind the scenes. As the industry shifts toward a “net pricing” model, traditional rebate-driven strategies are weakening, forcing manufacturers, PBMs, and pharmacies to rethink how value and profits are generated. Today's featured guest is Dr. Ndidiamaka Okpareke PharmD for Congress Dr. Ndidiamaka “Didi” Okpareke, PharmD, is a pharmacist, entrepreneur, and political candidate running for Congress in New Mexico's 1st Congressional District. A first-generation Nigerian-American, she built her career in healthcare after graduating from the University of New Mexico College of Pharmacy and went on to found and lead a successful compounding pharmacy serving her community.  Motivated by nearly two decades of patient care experience, Okpareke entered the political arena to address challenges such as healthcare access, rising costs, and the shortage of providers in New Mexico. Running as a Republican, she emphasizes strengthening healthcare systems, supporting economic growth, and preserving opportunity for future generations, positioning herself as a community-focused leader bringing frontline healthcare insight into public policy.  This special episode highlights how TJM Labs is redefining pharmacy operations through AI-driven automation, bringing together insights from industry leaders Bhavesh Patel, PharmD—CEO of Carepoint Pharmacy—and Jonathan Adly, PharmD, MBA—CEO of TJM Labs. At the center of the conversation is how modern pharmacies are facing rising prescription volumes, staffing constraints, and increasing operational complexity, and why traditional manual workflows can no longer keep pace. TJM Labs addresses this challenge by deploying AI-powered “digital workers” that automate tasks like prescription intake, data entry, and patient communication—allowing pharmacy teams to shift their focus back to patient care and clinical decision-making.  Through the lens of both operator and innovator, the discussion explores how AI is not replacing pharmacy professionals, but augmenting them—reducing burnout, improving accuracy, and enabling scalable growth. With automation handling up to the majority of repetitive workload and delivering measurable ROI, TJM Labs represents a new model where technology and pharmacy expertise work together to create more efficient, patient-centered operations. 

The Nurses Report on America Out Loud with Ashley Caputo, RN, FMP – This episode of The Nurses Report explores how Pharmacy Benefit Managers shape access to medications, often leading to delays and denials. It examines carve-outs, ERISA limits, and real patient impacts while highlighting the growing need for transparency, advocacy, and patient-centered decision-making in today's healthcare system...

Tennessee lawmakers have passed a major pharmacy reform bill aimed at pharmacy benefit managers, or PBMs, by barring companies from owning both a PBM and a pharmacy. The legislation is widely seen as targeting CVS Health, which owns Caremark and operates pharmacies across the state. Supporters say the bill is designed to curb vertical integration, restore fair competition, and protect independent pharmacies from reimbursement practices they view as harmful to patient access and community pharmacy survival. CVS has pushed back hard, warning that the new law could force it to shut down its 134 Tennessee pharmacy locations and trigger a legal challenge. The company argues the measure would reduce access for patients and does not directly address broader PBM issues like pricing or formularies. This Tennessee fight reflects a larger national battle over PBM reform, pharmacy ownership, market power, and the future of prescription drug access.  

Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members."  "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Download the transcript here  

Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members."  "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Listen to the podcast here  

In this episode, Suzanne Spradley and Chase Cannon discuss two recent circuit court decisions and their impact on employer-sponsored group health plans. Suzanne first discusses a Sixth Circuit decision involving a state law that attempts to regulate PBMs. Suzanne and Chase walk through Supreme Court precedent that appears to be driving states to enact PBM laws, and they explain how ERISA preemption is at the heart of it all. Suzanne concludes the podcast by outlining another federal decision relating to a fiduciary breach claim of an employer group health plan.

Nearly one billion prescriptions are abandoned at the pharmacy counter every year, often because patients are blindsided by the cost.This week, co-host Halle Tecco is joined by Wendy Barnes, President and CEO of GoodRx, to discuss the chaos of prescription drug pricing, the murky world of Pharmacy Benefit Managers (PBMs), and how digital tools are changing patient affordability. They break down the layered system of manufacturers, payers, and pharmacies that creates inconsistent pricing, and explore the current push for greater transparency.We cover:The cascade of drug pricing: from initial manufacturer costs and rebates to payer and pharmacy contracts, which results in vast price variability for consumersWhat it would take to get to price transparency in drug pricingThe current pressures on PBMs, including efforts to ban "spread" and the practice of offshoring rebate contracting for tax advantagesWhy pharmacies haven't gone online like other areas of consumer goodsThe future of medication access, including the growth of pharma's direct-to-patient programs and the low current adoption of home delivery despite widespread retail pharmacy closures— About our guest:Wendy Barnes is the President and CEO of GoodRx. She has over 30 years of leadership experience across the pharmacy and medical benefit industry. Most recently, Wendy served as CEO of RxBenefits, where she led the company in providing pharmacy benefit support to more than 2,000 self-insured clients, representing over 3 million lives. Prior to that, she served as President of Express Scripts Pharmacy, overseeing operations for 100 million beneficiaries. Her leadership spans roles at Rite Aid, Premier Inc., and the U.S. Air Force, where she served as a Medical Service Corps Officer. She holds a B.S. degree in Biochemistry from the United States Air Force Academy and an M.B.A. degree from the University of Alaska Anchorage.—

Mississippi Today health reporters Gwen Dilworth and Sophia Paffenroth review what the Legislature did (or didn't) accomplish with PBMs, Medicaid, abortion drugs and other health policy issues this session.

We're back with our monthly rundown of the top headlines in health tech!Today, Halle flies solo to share the biggest stories that shaped Q1, from the rising pressures on PBMs to how consumers are using AI.Stories covered:What's happening to PBMs (it's not pretty)New data from Rock Health on consumer use of AISocial media companies find liable for addictive designHealthcare hiring is slowing as efficiency becomes the focusHave we finally bent the healthcare cost curve in the United States?—The Heart of Healthcare podcast was nominated for a Webby award! We'd so appreciate if you could create a quick account and vote for us here. —

Last year, his independent pharmacy spent $13 million on brand-name drugs for patients processed by the three biggest Pharmacy Benefit Managers (PBMs) which earned a profit margin of 0.01%.In this episode, Halle speaks with Alec Ginsberg, owner and fourth-generation pharmacist at C.O. Bigelow, the oldest surviving apothecary–pharmacy in the United States. Alec is fighting against the forces squeezing independent pharmacies and charting a course for the future of the pharmacist.We cover:How the roll-up of PBMs, health plans, and retail pharmacies changed everythingWhat led him to remove his pharmacy's Rx-filling robotThe dramatic decline of independent pharmacies along with the closures of big box pharmacy storesThe one health policy he would put in place today to save independent pharmaciesThe history of the pharmacist's role and what's nextWhat he really thinks about compounding pharmacies and the Hims vs. Novo lawsuit—About our guest: Alec Wade Ginsberg is the fourth-generation pharmacist, owner, and Chief Operating Officer of C.O. Bigelow Apothecary, America's oldest pharmacy, founded in 1838 and still operating in New York City's West Village. With a Doctor of Pharmacy degree from the University of North Carolina Eshelman School of Pharmacy, Alec bridges the clinical world of pharmacy with the realities of modern consumer culture.At Bigelow, he oversees the brick-and-mortar beauty retail and pharmacy operations, navigating everything from prescription drug shortages to the pressures of today's PBM-dominated marketplace. Beyond the counter, Alec is the founder and writer of Drugstore Cowboy, a weekly newsletter that dissects the intersection of drugs, business, and consumer culture — making the hidden mechanics of the U.S. healthcare system both understandable and entertaining for thousands of readers.His work has been featured across national media, and he's become a trusted voice for translating complex pharmaceutical issues — from GLP-1s to compounding to drug pricing — into plain English. Alec's mission is simple: to make Americans smarter about the pills in their cabinets and the system that puts them there.—Show notes:Drugstore Cowboy - Alec's free and super interesting newsletterC.O. Bigelow - The Nation's Oldest ApothecaryVirtual GLP-1 startups: Pill mills or the future of obesity care?—