For this special episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Andrew Barnell, CEO of <a href="https://www.geneoscopy.com/" target="_blank">Geneoscopy</a>, joins Justin Venneri in the studio for an insightful discussion about colorectal cancer (CRC) screening in observance of <a href="https://colorectalcancer.org/get-involved/advocate/colorectal-cancer-awareness-month" target="_blank">National CRC Awareness Month</a>! Andrew explains how he and his "very talented" sister, Erica Barnell, MD, PhD, co-founded Geneoscopy to develop diagnostic tests using RNA biomarkers extracted from stool samples. Their newly FDA-approved test, <a href="https://colosense.com/" target="_blank">ColoSense™</a>, provides a non-invasive alternative to traditional colonoscopies.Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses the urgent need for increased screening awareness and greater access to screening tools, noting that employers can help overcome barriers to screening through education and by encouraging engagement in wellness programs. Other topics covered include:<ul><li>Over 135,000 people are diagnosed with CRC every year, and despite CRC being one of the most preventable cancers with good long-term survival rates following treatment, 50,000 people die from it annually. </li><li>Preventive screenings are increasingly covered with no patient out-of-pocket costs, but insurers' expenses are rising.</li><li>Increasing early screening is crucial: 30-40% of eligible individuals remain unscreened, particularly in the 45-49 age group.</li><li>Geneoscopy's decentralized clinical trial and overall use of technology to conduct its pivotal FDA approval study virtually, which increased patient diversity and efficiency.</li><li>Regulatory challenges remain: FDA approval is just one step; Medicare coverage and guideline inclusion are key hurdles.</li><li>Bringing targeted therapy approaches to autoimmune diseases like IBD to improve patient outcomes and reduce costs is Geneoscopy's next goal.</li></ul>Related Content<ul><li><a href="https://cdn.prod.website-files.com/66181b36aa48913ffd698dc6/67e68e2cff554923cce6287c_Multitarget%20Stool%20RNA%20Test%20for%20Colorectal%20Cancer%20Screening%20JAMA%2010.23-1.pdf" target="_blank">Multitarget Stool RNA Test for Colorectal Cancer Screening</a>. Barnell EK, Wurtzler EM, La Rocca J, et al. JAMA. 2023;330(18):1760–1768. doi:10.1001/jama.2023.22231</li><li><a href="https://www.cap-rx.com/insights/pharmacogenomics-pgx-101-what-you-need-to-know-for-rx-programs" target="_blank">Pharmacogenomics (PGx) 101: What You Need to Know for Rx Programs</a></li></ul>Reference Materials/Other Links (courtesy of Geneoscopy)<ul><li><a href="https://www.acpjournals.org/doi/10.7326/ANNALS-24-00910?" target="_blank">Projected Impact and Cost-Effectiveness of Novel Molecular Blood-Based or Stool-Based Screening Tests for Colorectal Cancer</a>. Ladabaum U, Mannalithara A, Schoen RE, Dominitz JA, Lieberman D. Ann Intern Med. 2024 Dec;177(12):1610-1620. doi: 10.7326/ANNALS-24-00910. Epub 2024 Oct 29. PMID: 39467291.</li><li><a href="https://www.cancer.gov/types/colorectal" target="_blank">Colorectal Cancer—Patient Version</a>. National Cancer Institute (NCI)</li><li><a href="https://www.ajpmonline.org/article/S0749-3797(11)00265-0/abstract" target="_blank">Productivity savings from colorectal cancer prevention and control strategies</a>. Bradley CJ, Lansdorp-Vogelaar I, Yabroff KR, Dahman B, Mariotto A, Feuer EJ, Brown ML. Am J Prev Med. 2011 Aug;41(2):e5-e14. doi: 10.1016/j.amepre.2011.04.008. PMID: 21767717; PMCID: PMC3139918.</li><li><a href="https://www.linkedin.com/company/geneoscopy" target="_blank">Follow Geneoscopy</a> on LinkedIn</li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

For this special episode of the Astonishing Healthcare podcast, Andrew Barnell, CEO of Geneoscopy, joins Justin Venneri in the studio for an insightful discussion about colorectal cancer (CRC) screening in observance of National CRC Awareness Month! Andrew explains how he and his "very talented" sister, Erica Barnell, MD, PhD, co-founded Geneoscopy to develop diagnostic tests using RNA biomarkers extracted from stool samples. Their newly FDA-approved test, ColoSense™, provides a non-invasive alternative to traditional colonoscopies. Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses the urgent need for increased screening awareness and greater access to screening tools, noting that employers can help overcome barriers to screening through education and by encouraging engagement in wellness programs.

AH060 - A New Approach to CRC Screening, with Geneoscopy

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, we discuss how modern technology - <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">Judi®</a> - brings efficiency to the labor union market with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services), Christie Peperato (Manager, Payment &amp; Operations), and Kelly Smith (Product Manager). Who knew that Capital Rx has an hours banking system? Why did we build one? Well, every hour a union worker works may be tracked and "banked" for benefits eligibility purposes. So, those hours and the accuracy of the reporting matter... a lot. And as Christie describes, it's been a manual, "painful" process forever. After Mike explains the unique needs of union clients and what hours banking is all about, Christie and Kelly dive into how this newly developed system alleviates the pain by automating the tracking of work hours and eligibility for health benefits and having everything, including payments, processed in one system. By removing the manual burden on union office managers and making it easy for contractors to submit the data, managers and plan administrators can focus on what matters most: taking care of members' needs. Want to help name the new system? Drop us an email. 😆Related Content<ul><li><a href="https://www.cap-rx.com/insights/12-new-judi-r-features-innovating-pharmacy-benefit-administration" target="_blank">12 New Judi® Features Innovating Pharmacy Benefit Administration</a></li><li><a href="https://www.cap-rx.com/insights/ah055---pharmacy-benefits-101-stop-loss-insurance-with-mike-miele-fsa-maaa" target="_blank">AH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAA</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-unveils-healthcares-first-unified-pharmacy-and-medical-claims-processing-platform" target="_blank">Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript, or to get in touch!

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

AH061 - Empowering Unions with Technology: A New "Hours Banking" System

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Bloomberg Intelligence's Jonathan Palmer (Sr. Equity Analyst &amp; Team Lead, Healthcare) joins us in the studio for a discussion about the work his team does and the evolving landscape of health tech. Palmer notes interest in Hinge Health's potential IPO and how the market's receptivity to tech-enabled healthcare companies has improved recently. While these companies face pressure to demonstrate profitability amid evolving market dynamics, there's optimism about innovation on several fronts. He also explains the impact of health policy uncertainty and questions about what the FDA, FTC, DOJ, and CMS will do on investors' ability to place bets: ambiguity causes market hesitation, and investors gravitate toward safe havens.The discussion also covers areas of focus for 2025, including:<ul><li>Palmer's favorite Vanguards of Healthcare podcast episodes and why he enjoys speaking with private company CEOs and venture capital leaders</li><li>Biopharma Innovation, including GLP-1s, oncology readouts</li><li>MedTech Advancements like surgical robotics, cardioablation, and evolving insulin delivery systems</li><li>Capital Spending Concerns as US providers and China's healthcare sector are under scrutiny</li><li>Healthcare Services: online pharmacy growth and Medicare Advantage trends</li></ul>Reference Materials Courtesy of Bloomberg Intelligence<ul><li><a href="https://cdn.prod.website-files.com/66181b36aa48913ffd698dc6/67dc72d07893b03e1abf2ce1_Health%20Insurers%20Government%20Funding%20Challenges%20Policy%20Outlook.pdf" target="_blank">North America Managed-Care Policy Outlook</a></li><li><a href="https://cdn.prod.website-files.com/66181b36aa48913ffd698dc6/67dc72d17558acf3c995b4a1_2025%20Outlook%20North%20America%20Health-Care%20Tech%2C%20Distribution.pdf" target="_blank">N.A. Health-Care Tech, Distribution: 2025 Outlook</a></li></ul>Related Content<ul><li><a href="https://www.cap-rx.com/insights/vanguards-of-health-care-how-capital-rx-is-fixing-americas-broken-drug-pricing" target="_blank">Vanguards of Health Care: How Capital Rx is Fixing America's Broken Drug Pricing</a></li><li><a href="https://www.cap-rx.com/insights/ah057---how-first-movers-are-taking-control-of-their-health-plans-in-2025-with-jeff-hogan" target="_blank">AH057 - How First-Movers are Taking Control of their Health Plans in 2025, with Jeff Hogan</a></li><li><a href="https://www.cap-rx.com/insights/ah047---what-project-2025-rfk-jr-and-dr-oz-could-mean-for-the-business-of-healthcare-under-trump" target="_blank">AH047 - What Project 2025, RFK Jr., and Dr. Oz Could Mean for the Business of Healthcare Under Trump</a></li><li><a href="https://www.cap-rx.com/insights/ah046---whats-hot-in-and-around-the-pharmacy-supply-chain-with-rsms-tom-evegan" target="_blank">AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, Bloomberg Intelligence's Jonathan Palmer (Sr. Equity Analyst & Team Lead, Healthcare) joins us in the studio for a discussion about the work his team does and the evolving landscape of health tech. Palmer notes interest in Hinge Health's potential IPO and how the market's receptivity to tech-enabled healthcare companies has improved recently. While these companies face pressure to demonstrate profitability amid evolving market dynamics, there's optimism about innovation on several fronts. He also explains the impact of health policy uncertainty and questions about what the FDA, FTC, DOJ, and CMS will do on investors' ability to place bets: ambiguity causes market hesitation, and investors gravitate toward safe havens.

AH059 - Healthcare Sector Update & Outlook, with Bloomberg Intelligence's Jonathan Palmer

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, host Justin Venneri speaks with Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. They dive into several <a href="https://www.cap-rx.com/insights/12-new-judi-r-features-innovating-pharmacy-benefit-administration" target="_blank">recent updates to the Judi® platform</a>, highlighting Judi's overall agility and how it aids in the administration of benefit plans for Capital Rx's clients. During the discussion, they also explore:<ul><li>Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.</li><li>Judi's ability to ingest historical claims data for seamless onboarding of new clients.</li><li>The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).</li><li>Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.</li><li>Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.</li><li>How Judi Health aims to streamline member care and improve the patient experience.</li></ul>Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.Related Content<ul><li><a href="https://www.cap-rx.com/insights/capital-rx-receives-a-us-utility-patent-covering-its-enterprise-health-platform---judi-r" target="_blank">Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-prior-authorizations" target="_blank">Pharmacy Benefits 101: Prior Authorizations</a></li><li><a href="https://www.cap-rx.com/insights/our-favorite-features-added-to-judi-r-in-2023" target="_blank">How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration</a></li><li><a href="https://www.cap-rx.com/insights/ah027---what-is-pharmacy-benefit-management-with-jillian-lonson-and-jean-beman-part-1" target="_blank">AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1</a></li><li><a href="https://www.cap-rx.com/insights/ah028---what-is-pharmacy-benefit-management-with-jillian-lonson-and-jean-beman-part-2" target="_blank">AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Liya Lomsadze (Director, Product Management) at Capital Rx. Liya discusses her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims product. They dive into recent updates to the Judi® platform, particularly improvements to the Prior Authorization Tool, including Medicare and Medical PA case processing and a supervisor dashboard for managing PA requests, how Judi can easily ingest data, Capital Rx's M3P and Formulary Management solutions, and the Agility of Tags & Overrides.

AH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya Lomsadze

On Episode 57 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, host Justin Venneri welcomes Jeff Hogan, President of Upside Health Advisors, back to the show to discuss the major trends he observed in healthcare procurement and plan management in 2024 and areas of focus in 2025. Jeff highlights the evolving role of employer fiduciaries under the Consolidated Appropriations Act of 2021 (CAA), building on Episode 30 and re-emphasizing the necessity of real-time data access and process-driven strategic decision-making. He explains how employers must take greater accountability for healthcare spending, moving beyond reliance on traditional insurance networks (BUCAHs) and considering alternative care delivery models; and adds that provider organizations must adapt to align care delivery with consumer needs or risk obsolescence.The discussion also covers the increasing use of analytics - including platforms like HOMA Health - or outside resources, like <a href="https://www.cap-rx.com/insights/ah052---erisa-insights-challenges-compliance-in-modern-healthcare-with-nick-welle" target="_blank">Nick Welle explained on Episode 52</a>, to help plan employer plan sponsors manage costs and their vendor contracts, PBM reform, and point solution fatigue. Finally, Jeff outlines key priorities for 2025, including fiduciary compliance, confirming the removal of gag clauses from contracts, and greater transparency in broker compensation to ensure better alignment between healthcare purchasers and providers.Related Content<ul><li><a href="https://www.cap-rx.com/insights/replay---strategic-well-being-rethinking-health-benefits-to-empower-employees-and-drive-impact" target="_blank">Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact</a></li><li><a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a></li><li><a href="https://www.cap-rx.com/insights/best-of-24-ah041---erisa-litigation-outlook-and-meeting-caa-requirements-what-can-plan-fiduciaries-do" target="_blank">Best of '24! AH041 - ERISA Litigation Outlook and Meeting CAA Requirements, What Can Plan Fiduciaries Do?</a></li><li><a href="https://www.cap-rx.com/insights/signs-it-is-time-to-change-your-pbm-vendor-and-how-to-overcome-common-hesitations" target="_blank">Signs it is time to change your PBM vendor, and how to overcome common hesitations</a></li></ul>To learn more about Upside Health Advisors, <a href="https://theupsideeffect.com/contact-us" target="_blank">click here,</a> or you can find Jeff on <a href="https://www.linkedin.com/in/jeffhogan06/" target="_blank">LinkedIn</a>.Resources Mentioned<ul><li><a href="https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/Vizient_report_2025Trends" target="_blank">Vizient - 2025 Trends Report: Strategy is (finally) back in the driver’s seat</a></li><li><a href="https://phti.org/wp-content/uploads/sites/3/2024/06/PHTI-Virtual-MSK-Solutions-Assessment-Report-v1.0.pdf" target="_blank">Peterson Health Tech Institute - Virtual Musculoskeletal Solutions</a> (June 2024)</li><li><a href="https://phti.org/wp-content/uploads/sites/3/2023/09/ICER-PHTI-Assessment-Framework-for-Digital-Health-Technologies.pdf" target="_blank">ICER - Peterson Health Tech Institute: Assessment Framework for Digital Health Technologies </a>(Sept. 2023)</li><li><a href="https://phti.com/wp-content/uploads/sites/3/2024/03/PHTI-Digital-Diabetes-Mgmt-Assessment-Report-v1.0.pdf" target="_blank">Peterson Health Tech Institute - Digital Diabetes Management Solutions</a> (March 2024)</li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On Episode 57 of the Astonishing Healthcare podcast, host Justin Venneri welcomes Jeff Hogan, President of Upside Health Advisors, back to the show to discuss the major trends he observed in healthcare procurement and plan management in 2024 and areas of focus in 2025. Jeff highlights the evolving role of employer fiduciaries under the Consolidated Appropriations Act of 2021 (CAA), building on Episode 30 and re-emphasizing the necessity of real-time data access and process-driven strategic decision-making. He explains how employers must take greater accountability for healthcare spending, moving beyond reliance on traditional insurance networks (BUCAHs) and considering alternative care delivery models; and adds that provider organizations must adapt to align care delivery with consumer needs or risk obsolescence.

AH057 - How First-Movers are Taking Control of their Health Plans in 2025, with Jeff Hogan

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Justin Venneri chats with Angela Kalantarova, PharmD, a senior clinical programs manager at Capital Rx, about recent updates to <a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-medicare-star-ratings" target="_blank">Medicare's star ratings</a>. Angela shares her path to Capital Rx and experience working in managed care and on clinical programs, and she explains what's new for 2025: star measures for polypharmacy and concurrent use of opioids and benzodiazepines.The conversation highlights the positive impact early interventions can have and how innovative enterprise health technology like <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">Judi®</a> allows for real-time insights. As CMS proposes changes, such as possibly removing the MTM - medication therapy management - measure or others like limiting initial opioid supply, having the flexibility to react quickly helps immensely. Angela also provides some strategic insights into how to navigate the evolving landscape and achieve superior ratings.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah035---pharmacy-benefits-101-clinical-programs-with-bonnie-hui-callahan-pharmd" target="_blank">AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/impact-of-point-of-sale-duplicate-therapy-safety-alert-on-concomitant-dpp-4-inhibitor-and-glp-1-agonist-use-poster" target="_blank">Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use</a></li><li><a href="https://www.cap-rx.com/insights/ah005---star-ratings-mtm-cms-translation-requirements-with-jay-tran-pharmd" target="_blank">AH005 - Star Ratings, MTM, &amp; CMS Translation Requirements with Jay Tran, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/ah006---pharmacy-benefits-101-clinical-care-teams-with-amy-stockton-pharmd" target="_blank">AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, Justin Venneri chats with Angela Kalantarova, PharmD, a senior clinical programs manager at Capital Rx, about recent updates to Medicare's star ratings. Angela shares her path to Capital Rx and experience working in managed care and on clinical programs, and she explains what's new for 2025: star measures for polypharmacy and concurrent use of opioids and benzodiazepines.

AH056 - Medicare Star Ratings: Updates, How Judi® Helps, and More, with Angela Kalantarova, PharmD

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, we explore the nuances of stop-loss insurance with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services). With premiums on the rise due to high-cost claims reaching levels actuaries never thought possible, self-insured plan sponsors need new options and better tools to monitor their costs. Mike, who is a healthcare actuary by training, discusses everything from "What is stop-loss?" and who it's for to what's driving high-cost claims to new heights, the rise of a pharmacy-only stop-loss option, and options plan sponsors have to mitigate risk when "it's not a good time to be in a risk-taking business." Mike comments on broader cost drivers, using GLP-1s as an example, preliminary book-of-business trends (2024 vs. 2023), the importance of surveillance on emerging claims, and more! Related News &amp; Content:<ul><li><a href="https://www.benefitspro.com/2025/02/14/sun-life-sees-stop-loss-problems-spiking-will-it-force-employers-to-buy-fully-insured-coverage/" target="_blank">Sun Life sees stop-loss problems spiking: Will it force employers to buy fully insured coverage?</a> (BenefitsPro)</li><li><a href="https://www.cap-rx.com/insights/ah031---dissecting-pharmacy-cost-drivers-and-the-value-of-pmpm-with-kristin-begley-pharmd-and-mike-miele-fsa-maaa" target="_blank">AH031 - Dissecting Pharmacy Cost Drivers and the Value of PMPM, with Kristin Begley, PharmD, and Mike Miele, FSA, MAAA</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-unveils-healthcares-first-unified-pharmacy-and-medical-claims-processing-platform" target="_blank">Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

On this episode of the Astonishing Healthcare podcast, we explore the nuances of stop-loss insurance with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services). With premiums on the rise due to high-cost claims reaching levels actuaries never thought possible, self-insured plan sponsors need new options and better tools to monitor their costs. Mike, who is a healthcare actuary by training, discusses everything from "What is stop-loss?" and who it's for to what's driving high-cost claims to new heights, the rise of a pharmacy-only stop-loss option, and options plan sponsors have to mitigate risk when "it's not a good time to be in a risk-taking business."

AH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAA

This episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Guests AJ Loiacono (Co-Founder &amp; CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation &amp; Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively. Building on <a href="https://www.cap-rx.com/insights/ah007---theres-no-value-based-care-without-considering-pharmacy-with-sunil-budhrani-md" target="_blank">Episode 7 (with Sunil)</a> and <a href="https://www.cap-rx.com/insights/ah009---modern-technology-in-healthcare-enhancing-efficiency-security-with-ryan-kelly" target="_blank">Episode 9 (with Ryan Kelly, CTO)</a>, AJ and Sunil discuss how Judi Health’s innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies. AJ Loiacono reflects on the journey of building Judi Health and the importance of firsthand experience in workflow optimization. Dr. Budhrani stresses the importance of transparency and collaboration among the stakeholders, underlining how Judi Health can break down silos to improve care delivery and outcomes. They offer practical examples of how Judi Health can work, such as diabetic-specific plan designs and improved workflows for cancer care.The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.Related Content:<ul><li><a href="https://www.cap-rx.com/insights/capital-rx-unveils-healthcares-first-unified-pharmacy-and-medical-claims-processing-platform" target="_blank">Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform</a></li><li><a href="https://www.cap-rx.com/insights/setting-a-new-standard-for-the-future-of-pharmacy-benefit-administration" target="_blank">Setting a New Standard for the Future of Pharmacy Benefit Administration</a></li><li><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™</a></li><li><a href="https://www.cap-rx.com/insights/signs-it-is-time-to-change-your-pbm-vendor-and-how-to-overcome-common-hesitations" target="_blank">Signs it is time to change your PBM vendor, and how to overcome common hesitations</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

This episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders including patients, providers, and employers. Guests AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively. 
Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health’s innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies.

AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani

On Episode 53 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Bridget Mulvenne, VP of Business Development, joins Justin Venneri in the studio again to share highlights of her first full year of selling pharmacy benefit solutions ahead of her webinar on February 13: 5 Ways to Improve your PBM Procurement Process in 2025 (<a href="https://capitalrx.zoom.us/webinar/register/3617364547548/WN_19RWz0ieSMGehuz49qPfRA?hsCtaAttrib=184943325591#/registration" target="_blank">click here to learn more and register</a>). They discuss the evolving healthcare landscape, regulatory pressures, expanding indications for GLP-1s, and the need for transparency in pharmacy benefits. Bridget shares stories from the field, explaining why focusing on drug manufacturer revenue and breaking the industry’s dependence on rebates are so important and how modern technology helps provide real-time data access and actionable insights to plan sponsors. Previous AH episodes featuring Bridget:<ul><li><a href="https://www.cap-rx.com/insights/ah002---a-former-pharmacy-program-directors-view-on-controlling-pharmacy-costs" target="_blank">AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs</a></li><li><a href="https://www.cap-rx.com/insights/ah021---managing-pharmacy-costs-in-a-glp-1-world-with-bridget-mulvenna" target="_blank">AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna</a></li></ul>Bridget also shares insights on the evolving landscape of GLP-1 medications and their growing number of FDA-approved indications beyond diabetes and highlights the challenges plan sponsors face with coverage decisions, balancing short-term costs with potential long-term savings. Discussing Capital Rx’s <a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">Never Move Again™</a> offering, Bridget emphasizes its flexibility and appeal to sophisticated plan sponsors.Related Content:<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-pharmaceutical-rebates" target="_blank">Pharmacy Benefits 101: Pharmaceutical Rebates</a></li><li><a href="https://www.cap-rx.com/insights/our-clearinghouse-model-r-pharma-revenue-explained" target="_blank">Our Single-Ledger Model™ - Pharma Revenue Explained</a></li><li><a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

On Episode 53 of the Astonishing Healthcare podcast, Bridget Mulvenne, VP of Business Development, joins Justin Venneri in the studio again to share highlights of her first full year of selling pharmacy benefit solutions ahead of her webinar on February 13: 5 Ways to Improve your PBM Procurement Process in 2025 (click here to learn more and register). They discuss the evolving healthcare landscape, regulatory pressures, expanding indications for GLP-1s, and the need for transparency in pharmacy benefits. Bridget shares stories from the field, explaining why focusing on drug manufacturer revenue and breaking the industry’s dependence on rebates are so important and how modern technology helps provide real-time data access and actionable insights to plan sponsors.

AH053 - Selling Pharmacy Benefits: Relationships, Rebates, GLP-1s, and More, with Bridget Mulvenna

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Nick Welle, Partner &amp; Chair of the Health Benefits Practice at Foley &amp; Lardner LLP, joins host Justin Venneri in the studio for a discussion about ERISA and how employer plan fiduciaries can navigate a relatively complex set of responsibilities. With the recent developments around the J&amp;J lawsuit and interest in how that may progress following the dismissal of the allegations, and questions swirling about i) what the Trump administration will do regarding the ACA and ii) CAA compliance and reporting, the timing couldn't be better to publish Episode 52.They dive into common traps Nick has seen employers fall into, processes and resources to leverage to show that "homework" - i.e., reasonable due diligence - is being done on the vendors providing services to the plan and its members, and much more. The ability to see and evaluate plan data and costs has never been more important!Note that Nick's comments on this podcast are his own personal comments and do not represent any views or positions of the clients of Foley &amp; Lardner.Reference Materials for Plan Sponsors<ul><li><a href="https://www.foley.com/insights/publications/2021/11/employer-checklist-health-plan-price-rules-caa/" target="_blank">Employer Checklist for New Health Plan Price Transparency Rules and CAA</a></li><li><a href="https://www.foley.com/insights/publications/2024/09/final-mental-health-parity-rules-top-five-changes-status-quo/" target="_blank">Final Mental Health Parity Rules – Top Five Changes to the Status Quo</a></li></ul>Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah041---erisa-litigation-outlook-and-meeting-caa-requirements-what-can-plan-fiduciaries-do" target="_blank">AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?</a></li><li><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™</a></li><li><a href="https://www.cap-rx.com/insights/vive-2023-whats-behind-the-price-tag-of-medication-highlights#:~:text=The%20Consolidated%20Appropriations%20Act%20(CAA)%3A%C2%A0Kudos%20to%20the%20Department%20of%20Labor" target="_blank">The Consolidated Appropriations Act (CAA): Kudos to the Department of Labor</a> (AJ Loiacono at ViVE)</li></ul>To connect with Nick, <a href="https://www.foley.com/people/welle-nick-j/" target="_blank">CLICK HERE</a>.Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Nick Welle, Partner & Chair of the Health Benefits Practice at Foley & Lardner LLP, joins host Justin Venneri in the studio for a discussion about ERISA and how employer plan fiduciaries can navigate a relatively complex set of responsibilities.  With the recent developments around the J&J lawsuit and interest in how that may progress following the dismissal of the allegations, and questions swirling about i) what the Trump administration will do regarding the ACA and ii) CAA compliance and reporting, the timing couldn't be better to publish Episode 52.

AH052 - ERISA Insights: Challenges & Compliance in Modern Healthcare, with Nick Welle

For Episode 51 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, we spoke with Nick Opalich, CEO of <a href="https://hospicechoicerx.com/about-hospicechoice-rx/" target="_blank">HospiceChoice Rx</a>. We learned about how end-of-life care is evolving in the U.S., including the roles pharmacy and technology play in the hospice industry. Nick and host Justin Venneri discuss some similarities between the hospice pharmacy benefit management (PBM) and commercial PBM spaces, such as the importance of a great pharmacy network and independent pharmacies, why the drug price index matters (NADAC vs. AWP), medication access, and disconnected systems.A former pharmacy owner himself, Nick explains the importance of helping hospice providers control drug spend, which is usually the second highest cost behind labor for providers, and reimbursement trends/pressure. He also touches on dispense fees, the potential to improve ePrescribing, and leveraging AI for enhanced reporting.Related Content<ul><li><a href="https://www.cap-rx.com/insights/what-is-nadac-how-does-it-differ-from-awp" target="_blank">What is NADAC &amp; How Does It Differ From AWP?</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-the-importance-of-the-network" target="_blank">Pharmacy Benefits 101: The Importance of the Network</a></li></ul>For Reference<ul><li>Hospice industry <a href="https://www.nhpco.org/wp-content/uploads/NHPCO-Facts-Figures-2024.pdf" target="_blank">Facts &amp; Figures</a> (NHPCO, 2024)</li></ul>Thank you for listening, and check out <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more, including this episode's transcript!

For Episode 51 of the Astonishing Healthcare podcast, we spoke with Nick Opalich, CEO of HospiceChoice Rx, and learned about how end of life care is evolving in the U.S., including the roles pharmacy and technology play in the hospice industry. Nick and host Justin Venneri discuss some similarities between the hospice pharmacy benefit management (PBM) and commercial PBM spaces, such as the importance of a great pharmacy network and independent pharmacies, why the drug price index matters (NADAC vs. AWP), medication access, and disconnected systems.

AH051 - Why Drug Prices & Modern Tech Matter in Hospice Care, Too, with Nick Opalich

On this 50th episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Capital Rx Vice President of Business Development Hope Nakazato, PharmD, joins Justin Venneri to discuss her observations, based on diverse industry experience, about the three most common friction points between plan sponsors and pharmacy benefit managers (PBMs): lack of execution, poor communication, and inflexibility. So, why have plan sponsors dealt with the status quo and rising costs for so long? Great question.Hope uses the book, <a href="https://www.amazon.com/Who-Moved-My-Cheese-Amazing/dp/0399144463" target="_blank">"Who Moved My Cheese?"</a>, by Dr. Spencer Johnson, to explain the fear of change, as well as three things people can look for in a true partner who will work with them in a collaborative and generally supportive way. If a new PBM or other vendor is aligned, consistent, and future-proof, change won't be as scary as it may seem, and plan sponsors can make more strategic decisions benefiting the plan and its members. Hope also shares the advice she'd give her younger self, as well as the most astonishing thing she's seen over the years (hint: it relates to drug prices).Related Content<ul><li><a href="https://www.cap-rx.com/insights/capital-rx-adds-more-than-80-new-partnerships-in-2024-and-eyes-another-year-of-record-growth-in-2025-2" target="_blank">Capital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefit-procurement-how-to-ensure-that-savings-materialize" target="_blank">Pharmacy Benefit Procurement: How to Ensure That Savings Materialize</a></li><li><a href="https://www.cap-rx.com/insights/5-ways-to-improve-your-pbm-procurement-process-in-2024-2" target="_blank">Replay: 5 Ways to Improve Your PBM Procurement Process In 2024</a> (stay tuned for the 2025 edition!)</li><li><a href="https://www.cap-rx.com/insights/5-recommendations-for-an-optimal-pbm-deal-ebook" target="_blank">5 Recommendations for an Optimal PBM Deal</a> (free eBook)</li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

On this 50th episode of the Astonishing Healthcare podcast, Capital Rx Vice President of Business Development, Hope Nakazato, PharmD, joins Justin Venneri to share her observations, based on diverse industry experience, about the three most common friction points between plan sponsors and pharmacy benefit managers (PBMs): lack of execution, poor communication, and inflexibility. So, why have plan sponsors dealt with the status quo and its cost inflation for so long? Listen in to find out.

AH050 - PBM Pain Points and Overcoming the Fear of Change, with Hope Nakazato, PharmD

On this <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> episode, return guests Heidi McKinnon, PharmD, CHC (Head of Compliance at Capital Rx), and Symara Schmidt, PharmD, PMP, CHC, BCGP (Director, Compliance Programs), join host Justin Venneri in the studio for another Pharmacy Benefits 101 discussion about Pharmacy Audits, including how pharmacy benefit managers (PBMs) and pharmacies can work together to avoid issues and improve compliance - it is possible!They explain everything from common audit triggers and types of audits to how the audits work and resources pharmacies can leverage to improve compliance and reduce friction/errors. Why are compliance executives at a PBM explaining all this? Well, it's an important topic, and there are misperceptions about pharmacy audits. There can be positive outcomes, and reducing fraud, waste, and abuse in the pharmacy supply chain is always a good thing.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah023---compliance-matters-with-heidi-mckinnon-pharmd-chc" target="_blank">AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC</a></li><li><a href="https://www.cap-rx.com/insights/ah025---empowering-pharmacists-with-naspas-krystalyn-weaver-pharmd-jd" target="_blank">AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD</a></li></ul>Reference Materials<ul><li><a href="https://www.cap-rx.com/pharmacists#pharmacists-forms:~:text=Pharmacy%20Provider%20Manual" target="_blank">The Capital Rx Pharmacy Provider Manual</a></li><li><a href="https://www.pcmanet.org/wp-content/uploads/2023/01/PBM-Pharmacy-Audit-White-Paper.pdf" target="_blank">PHARMACY AUDITS, An Important Tool for Fighting Fraud, Waste, and Abuse and Protecting Patients</a></li><li><a href="https://paasnational.com/" target="_blank">PAAS National - Home Page</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

On this Astonishing Healthcare podcast episode, return guests Heidi McKinnon, PharmD, CHC (Head of Compliance at Capital Rx), and Symara Schmidt, PharmD, PMP, CHC, BCGP (Director, Compliance Programs), join host Justin Venneri in the studio for another Pharmacy Benefits 101 discussion about Pharmacy Audits, including how pharmacy benefit managers (PBMs) and pharmacies can work together to avoid issues and improve compliance - it is possible!

AH049 - Pharmacy Benefits 101: Pharmacy Audits

What better way to kick off 2025 than having <a href="https://www.linkedin.com/in/ericbrickermd/" target="_blank">Dr. Eric Bricker</a> join us in the studio for Episode 48 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>? Known for his entertaining and educational videos covering all sorts of hot topics in and around healthcare and employer/employee benefits, Dr. Bricker and host Justin Venneri discuss the issues of high-cost drugs and access to claims data - two topics he recently covered on <a href="https://www.youtube.com/channel/UC8Hr2D7Y5rqzb63U-1fPXrg" target="_blank">AHealthcareZ - Healthcare Finance Explained</a> - that should be top of mind for plan sponsors this year as pharmacy costs continue to rise.Dr. Bricker shares several ways employers, depending on their size and risk tolerance, may be able to navigate the challenge of rising pharmaceutical costs for orphan and other expensive drugs - including GLP-1s. He also explains how the RFP process can be used to secure the plan's claim data, which is necessary to meet fiduciary obligations.While every plan is unique, most plan sponsors face similar challenges that the traditional PBM model isn't flexible or aligned enough to solve. Dr. Bricker is astonished by the complacency out there, but he does see the potential for an acceleration in the pace of change this year and next... tune in to hear why, and check out the links below for more information!AHealthcareZ Reference Videos<ul><li><a href="https://www.youtube.com/watch?v=JQdvi6g0mog" target="_blank">High Cost Orphan Disease Drugs Explained</a></li><li><a href="https://www.youtube.com/watch?v=rSBCjd0a16c" target="_blank">Do Employers Own Their Claims Data? It's Complicated.</a></li></ul>Related Content<ul><li><a href="https://www.cap-rx.com/insights/replay-cracking-the-code-unraveling-specialty-drug-costs-pbm-profits" target="_blank">Replay - Cracking the Code: Unraveling Specialty Drug Costs &amp; PBM Profits</a></li><li><a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a></li><li><a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

What better way to kick off 2025 than having Dr. Eric Bricker join us in the studio for Episode 48 of the Astonishing Healthcare podcast? Known for his entertaining and educational videos covering all sorts of hot topics in and around healthcare and employer/employee benefits, Dr. Bricker and host Justin Venneri discuss the issues of high-cost drugs and access to claims data - two topics he recently covered on AHealthcareZ - Healthcare Finance Explained - that should be top of mind for plan sponsors this year as pharmacy costs continue to rise.

AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker

On this final encore episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> this year, we're replaying Episode 41, which featured three experts weighing in on rising litigation against employers and pharmacy benefit managers (PBMs) and was one of our most popular. We also want to take the opportunity to say, "Happy Holidays and New Year!" and thank our listeners and guests this year, including current and former colleagues; we couldn't have done it without you!In Episode 41, we discussed what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson &amp; Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode built on previous conversations, including <a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a>.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah004---data-fiduciary-responsibility-and-reversing-trend-with-jeff-hogan" target="_blank">AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan</a></li><li><a href="https://www.cap-rx.com/insights/the-consolidated-appropriations-act-prescription-drug-data-collection-rxdc-new-rules-regulations-equal-new-responsibilities" target="_blank">The Consolidated Appropriations Act &amp; Prescription Drug Data Collection (RxDC): New Rules &amp; Regulations Equal New Responsibilities</a></li><li><a href="https://www.cap-rx.com/insights/self-funded-plans-ignore-the-consolidated-appropriations-act-at-their-peril" target="_blank">Self-funded plans ignore the Consolidated Appropriations Act at their peril</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this final encore episode of the Astonishing Healthcare podcast this year, we're replaying Episode 41, which featured three experts weighing in on rising litigation against employers and pharmacy benefit managers (PBMs) and was one of our most popular. We also want to take the opportunity to say, "Happy Holidays and New Year!" and thank our listeners and guests this year, including current and former colleagues; we couldn't have done it without you!

Best of "24! AH041 - ERISA Litigation Outlook and Meeting CAA Requirements, What Can Plan Fiduciaries Do?

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

Episode 20 of the Astonishing Healthcare podcast caught some folks' attention, as it featured Capital Rx Co-Founder and CEO AJ Loiacono and 3 Axis Advisors President/46brooklyn Research CEO Antonio Ciaccia. It's an episode you must listen to if your work or interests involve drug prices in any way. NADAC - national average drug acquisition cost - was the focus of our discussion on this episode, which was among the most downloaded and streamed episodes in 2024, and with PBM reform and drug prices top of mind, what better time to highlight it?

Best of '24! AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio Ciaccia

This <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> episode covers the potential future of US healthcare policy under the Trump administration, focusing on the business of healthcare services and possible changes to Medicare and Medicaid, support for telehealth, solving workforce issues, and managing chronic diseases. Our guest from Episode 13, <a href="https://www.cap-rx.com/insights/ah013---redefining-virtual-care-a-blueprint-for-effective-rpm-with-robert-longyear" target="_blank">Redefining Virtual Care: A Blueprint for Effective RPM,</a> Robert Longyear, Co-Founder of Avenue Health, returns to the show and shares his view from K Street after reviewing Project 2025 and evaluating what RFK Jr. and Dr. Mehmet Oz could prioritize in their roles.Robert shares the highlights of his analysis, including what he found most interesting and what he'll be watching for on payment policy (e.g., there's bipartisan support for payment reform and price transparency), potential changes to Medicare Advantage and Medicaid, pediatric care, how to reduce administrative burden and alleviate provider burnout, abortion policies, the use of artificial intelligence, and access to patient data. If health policy matters to you, this episode is a "must-listen!"Related Content<ul><li><a href="https://longyearhealth.substack.com/p/analyzing-health-policy-priorities" target="_blank">Analyzing Health Policy Priorities under RFK, Jr. and Dr. Oz</a> (Nov 27)</li><li><a href="https://longyearhealth.substack.com/p/what-to-expect-in-health-policy-from?utm_source=publication-search" target="_blank">What to Expect in Health Policy from the Next Trump Administration </a>(Project 2025 Analysis; Nov 7)</li><li><a href="https://longyearhealth.substack.com/p/digital-health-technologies-in-rural" target="_blank">Digital Health Technologies in Rural Health: Bridging the Gap in Care Access and Delivery </a>(Nov 26)</li><li><a href="https://www.cap-rx.com/insights/ah046---whats-hot-in-and-around-the-pharmacy-supply-chain-with-rsms-tom-evegan" target="_blank">AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan</a></li></ul>Visit <a href="https://longyearhealth.substack.com/" target="_blank">Health Tech Happy Hour</a> for more of Robert's work.For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

This Astonishing Healthcare podcast episode covers the potential future of US healthcare policy under the Trump administration, focusing on the business of healthcare services and possible changes to Medicare and Medicaid, support for telehealth, solving workforce issues, and managing chronic diseases. Our guest from Episode 13, Robert Longyear, Co-Founder of Avenue Health, returns to the show and shares his view from K Street after reviewing Project 2025 and what RFK Jr. and Dr. Mehmet Oz could prioritize in their roles.

AH047 - What Project 2025, RFK Jr., and Dr. Oz Could Mean for the Business of Healthcare Under Trump

On this <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> episode, Tom Evegan, Principal, National Consulting Leader, Life Sciences at RSM, a leading provider of tax, assurance, and consulting services in the US, joins Justin Venneri for a discussion about topics ranging from health policy to drug pricing and how to provide equitable drug access. Tom shares his background and path to RSM, explaining how his experiences at a major pharmaceutical manufacturer, pharmacy benefit manager (PBM), and a biotech launching a new therapy shaped his experience and aided him in becoming a "gross-to-net expert."Tom has helped hundreds of drug manufacturers launch, acquire, or divest assets and bring products from the regulatory phase to commercialization, so he's seen a lot and pays close attention to issues impacting drug prices and market access. Given his broad experience across the pharmaceutical supply chain, almost no topic is off the table. The conversation dives into the Inflation Reduction Act (IRA), the Chevron Ruling and 340B program, AI, why rebates likely aren't going anywhere soon, and the most astounding thing Tom's seen (hint: it relates to GLP-1s)!Related Content<ul><li><a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a></li><li><a href="https://www.cap-rx.com/insights/ah021---managing-pharmacy-costs-in-a-glp-1-world-with-bridget-mulvenna" target="_blank">AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna</a></li><li><a href="https://www.cap-rx.com/insights/what-is-nadac-how-does-it-differ-from-awp" target="_blank">What is NADAC &amp; How Does It Differ From AWP?</a></li><li><a href="https://www.cap-rx.com/insights/ah022---pharmacy-benefits-101-pharmaceutical-rebates-with-ben-schuster" target="_blank">AH022 - Pharmacy Benefits 101: Pharmaceutical Rebates, with Ben Schuster</a></li></ul>To connect with Tom or for more information about RSM's Life Sciences Group/Management Consulting Services, please visit:<ul><li>Connect with <a href="https://www.linkedin.com/in/tom-evegan-67a0934/" target="_blank">Tom Evegan (LinkedIn)</a></li><li><a href="https://rsmus.com/industries/life-sciences.html" target="_blank">Life Sciences | Industries | RSM US</a></li><li><a href="https://rsmus.com/insights/industries/life-sciences/scaling-at-the-speed-of-change-biopharma.html" target="_blank">Scaling at the Speed of Change: Biopharma</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this Astonishing Healthcare podcast episode, Tom Evegan, Principal, National Consulting Leader, Life Sciences at RSM, a leading provider of tax, assurance, and consulting services in the US, joins Justin Venneri for a discussion about topics ranging from health policy to drug pricing and how to provide equitable drug access. Tom shares his background and path to RSM, explaining how his experiences at a major pharmaceutical manufacturer, pharmacy benefit manager (PBM), and a biotech launching a new therapy shaped his experience and aided him in becoming a "gross-to-net expert."

AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan

Our first "Best of" <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> episode goes back to the beginning. For those who have been listening, "Thank you!" - we'll be back with a new episode next week. For new listeners, A LOT has happened since our co-founder and CEO AJ Loiacono kicked things off, including, but not limited to:<ul><li><a href="https://www.cap-rx.com/insights/new-york-city-fc-and-capital-rx-announce-sleeve-partnership" target="_blank">New York City FC and Capital Rx Announce Sleeve Partnership</a></li><li><a href="https://www.cap-rx.com/insights/prime-therapeutics-and-capital-rx-enter-into-transformative-strategic-alliance" target="_blank">Prime Therapeutics and Capital Rx Enter Into Transformative Strategic Alliance</a></li><li><a href="https://www.cap-rx.com/insights/capital-rxs-customer-care-team-wins-5-stevie-r-awards-for-customer-service" target="_blank">Capital Rx's Customer Care Team Wins 5 Stevie® Awards for Customer Service</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-launches-never-move-again-tm-enabling-self-funded-plan-sponsors-to-perpetually-access-the-best-drug-prices-without-ever-having-to-reimplement-a-plan-reissue-cards-or-expose-members-to-unnecessary-disruption" target="_blank">Capital Rx Launches </a><a href="https://www.cap-rx.com/insights/capital-rx-launches-never-move-again-tm-enabling-self-funded-plan-sponsors-to-perpetually-access-the-best-drug-prices-without-ever-having-to-reimplement-a-plan-reissue-cards-or-expose-members-to-unnecessary-disruption" target="_blank">Never Move Again™</a><a href="https://www.cap-rx.com/insights/capital-rx-launches-never-move-again-tm-enabling-self-funded-plan-sponsors-to-perpetually-access-the-best-drug-prices-without-ever-having-to-reimplement-a-plan-reissue-cards-or-expose-members-to-unnecessary-disruption" target="_blank">, Enabling Self-Funded Plan Sponsors to Perpetually Access the Best Drug Prices Without Ever Having to Reimplement a Plan</a></li><li><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Replay - Build a Lasting Pharmacy Benefit Strategy with </a><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Never Move Again™</a></li></ul>Fortunately, the overarching message/theme remains highly relevant, and AJ's experience and insights are always interesting to hear. Employer plan fiduciaries and health plans need aligned, focused, and unconflicted partners with next-generation technology to support their benefit programs (and operations) in a rapidly evolving environment. This goes well beyond just being transparent or passing through pharma revenue on the PBM side, which are bare minimum expectations at this point.All that said, Happy Thanksgiving, and if you like what you're hearing, please share the podcast with your network!For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

Our first "Best of" Astonishing Healthcare podcast episode goes back to the beginning. For those who have been listening, "Thank you!" - we'll be back with a new episode next week. For new listeners, a lot has happened since our co-founder and CEO AJ Loiacono kicked things off. Fortunately, the overarching message/theme remains highly relevant, and AJ's experience and insights are always interesting to hear. Employer plan fiduciaries and health plans need aligned, focused, and unconflicted partners with next-generation technology to support their benefit programs (and operations) in a rapidly evolving environment. This goes well beyond just being transparent or passing through pharma revenue on the PBM side, which are bare minimum expectations at this point.

Best of '24! AH001 - Building a PBM: Tech, Navigating Growth, and Delivering Value with AJ Loiacono

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Nisha Bhide, PharmD, joins Justin Venneri in the studio to discuss an integral aspect of pharmacy benefit management (PBM) - the formulary. They explore everything from what a formulary is to how they are created and P&amp;T committees, why and how often they change, the role <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> plays in managing a formulary efficiently, and the difference between open and closed formularies.*Nisha also dives into how specialty drugs fit into the equation, utilization management tools like prior authorization (PA), the role of formularies in helping manage low-cost generic or high-cost brand lists, and more!Related Content<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-what-is-a-formulary" target="_blank">Pharmacy Benefits 101: What is a Formulary?</a></li><li><a href="https://www.cap-rx.com/insights/replay-cracking-the-code-unraveling-specialty-drug-costs-pbm-profits" target="_blank">Replay - Cracking the Code: Unraveling Specialty Drug Costs &amp; PBM Profits</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-receives-a-us-utility-patent-covering-its-enterprise-health-platform---judi-r" target="_blank">Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®</a></li><li><a href="https://www.cap-rx.com/insights/ah035---pharmacy-benefits-101-clinical-programs-with-bonnie-hui-callahan-pharmd" target="_blank">AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.*If you'd like to dive into the details of a formulary, check out <a href="https://caprx.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68F7175D0DC1577226" target="_blank">Capital Rx's Freedom (Open) Formulary Lookup</a> or <a href="https://caprx.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B6860374AA7ED985B45" target="_blank">Capital Rx’s Liberty (Closed) Formulary.</a>

In this episode of the Astonishing Healthcare podcast, Nisha Bhide, PharmD, joins Justin Venneri in the studio to discuss an integral aspect of pharmacy benefit management (PBM) - the Formulary. They explore everything from what a formulary is to how they are created, why and how often they change, the role JUDI® plays in managing a formulary efficiently, the difference between open and closed formularies, and more!

AH045 - Pharmacy Benefits 101: Formularies & Formulary Management, with Nisha Bhide, PharmD

On Episode 44 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Andrew Gordon, LSW, joins host Justin Venneri for a discussion about the extensive primary research he's conducting on transparency and incentives in the U.S. Healthcare system. Gordon, who recently <a href="https://www.linkedin.com/posts/andrewgordon182_healthcare-transparency-pharmacy-activity-7247651601023217665-ZOY2/" target="_blank">interviewed Capital Rx co-founder and CEO AJ Loiacono</a>, explained how unexpected costs associated with an MRI sparked his curiosity, leading him to question why the healthcare system functions the way it does. He describes how he secured grants to explore - via 600+ interviews - what transparency means, where incentives are misaligned, fiduciary responsibility, and other factors that often contribute to patient confusion and wasteful spending.Why is payment expected regardless of a correct diagnosis? Does insurance need to be so confusing? Can the RFP process help set rational expectations? What's the best way to conduct primary research when everyone's time is at a premium? Andrew answers these questions and many more during today's discussion!Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a></li><li><a href=" https://www.cap-rx.com/insights/pharmacy-benefit-procurement-how-to-ensure-that-savings-materialize" target="_blank">Pharmacy Benefit Procurement: How to Ensure That Savings Materialize</a></li><li><a href="https://www.cap-rx.com/insights/ah014---the-rise-of-conversational-ai-healthcare-search-patient-journeys-will-never-be-the-same" target="_blank">AH014 - The Rise of Conversational AI: Healthcare Search &amp; Patient Journeys Will Never Be the Same</a></li><li><a href="https://www.cap-rx.com/insights/ah007---theres-no-value-based-care-without-considering-pharmacy-with-sunil-budhrani-md" target="_blank">AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD</a></li></ul>LinkedIn is the best way to <a href="https://www.linkedin.com/in/andrewgordon182/" target="_blank">get in touch with Andrew</a>.For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On Episode 44 of the Astonishing Healthcare podcast, Andrew Gordon, LSW, joins host Justin Venneri for a discussion about the extensive primary research he's conducting on transparency and incentives in the U.S. Healthcare system. Gordon, who recently interviewed Capital Rx co-founder and CEO AJ Loiacono, explained how unexpected costs associated with an MRI sparked his curiosity, leading him to question why the healthcare system functions the way it does. He describes how he secured grants to explore - via 600+ interviews - what transparency means, where incentives are misaligned, fiduciary responsibility, and other factors that often contribute to patient confusion and wasteful spending.

AH044 - Searching for Answers: Understanding Transparency, Alignment, and Incentives in Healthcare, with Andrew Gordon

This episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a> covers the ins and outs of two programs in the government sector - i.e., Medicare and Medicaid - and how modern technology - <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> - allows for more agility and flexibility in delivering care to Part D plan members and meeting CMS requirements. Capital Rx's Nash Albadarin, PharmD, explains changes to the Medication Therapy Management (MTM) criteria for 2025, which will increase membership, and provides an update on how MTM impacts Medicare star ratings. He also describes the purpose and structure of the Drug Management Program (DMP), which aims to help limit the risks associated with misuse and overuse of prescription drugs, namely opioids and other frequently abused, high-risk drugs.Additionally, Nash highlights the utility of these programs and their potential beyond the government sector, as MTM and mitigating the risks associated with opioids, for example, can help other plan sponsors better manage their populations.Related Content<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-whats-the-drug-management-program-dmp" target="_blank">Pharmacy Benefits 101: What's the Drug Management Program (DMP)?</a></li><li><a href="https://www.cap-rx.com/insights/ah005---star-ratings-mtm-cms-translation-requirements-with-jay-tran-pharmd" target="_blank">AH005 - Star Ratings, MTM, &amp; CMS Translation Requirements with Jay Tran, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-medicare-star-ratings" target="_blank">Pharmacy Benefits 101: Medicare Star Ratings</a></li><li><a href="https://www.cap-rx.com/insights/ah035---pharmacy-benefits-101-clinical-programs-with-bonnie-hui-callahan-pharmd" target="_blank">AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

This episode of the Astonishing Healthcare podcast covers the ins and outs of two programs in the government sector - i.e., Medicare and Medicaid - and how modern technology - JUDI® - allows for more agility and flexibility in delivering care to Part D plan members and meeting CMS requirements. Capital Rx's Nash Albadarin, PharmD, explains changes to the Medication Therapy Management (MTM) criteria for 2025, which will increase membership, and provides an update on how MTM impacts Medicare star ratings. He also describes the purpose and structure of the Drug Management Program (DMP), which aims to help limit the risks associated with misuse and overuse of prescription drugs, namely opioids and other frequently abused, high-risk drugs.

AH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmD

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Capital Rx's Vice President of Provider Relations, Kasi Ortiz, joins Justin Venneri in the studio to discuss the network component of pharmacy benefits. They discuss how modern technology - <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> - allows for flexibility and customization of the network to meet plan sponsors' varying needs based on their unique member populations. The network - the retail, mail order, or specialty pharmacies that dispense prescriptions for patients - is a crucial piece of the benefit design puzzle, and plan sponsors have options. Kasi expertly breaks down this subject, covering everything from the basics to building a NADAC-based commercial network, adding pharmacies to the network, the importance of transparency and independence (i.e., not owning dispensing assets), and how clients weigh cost vs. quality. She also explains how our agreements and networks are like Legos® (for Never Move Again™)!Related Content<ul><li><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Replay - Build a Lasting Pharmacy Benefit Strategy with </a><a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Never Move Again™</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-receives-a-us-utility-patent-covering-its-enterprise-health-platform---judi-r" target="_blank">Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®</a></li><li><a href="https://www.cap-rx.com/insights/ah020-----why-nadac-is-a-ray-of-sunshine-with-aj-loiacono-and-antonio-ciaccia" target="_blank">AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio Ciaccia</a></li></ul>Learn more about <a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">Never Move Again™ </a><a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">HERE</a>.For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, Capital Rx's Vice President of Provider Relations, Kasi Ortiz, joins Justin Venneri in the studio to discuss the network component of pharmacy benefits. They discuss how modern technology - JUDI® - allows for flexibility and customization of the network to meet plan sponsors' varying needs based on their unique member populations. The network - the retail, mail order, or specialty pharmacies that dispense prescriptions for patients - is a crucial piece of the benefit design puzzle, and plan sponsors have options.

AH042 - Pharmacy Benefits 101: The Network, with Kasi Ortiz

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, three experts weigh in on rising litigation against employers and pharmacy benefit managers (PBMs) and what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson &amp; Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode builds nicely on previous conversations, including <a href="https://www.cap-rx.com/insights/ah030---plan-sponsors-need-a-source-of-truth-get-your-data-now-find-it-with-jeff-hogan" target="_blank">AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now &amp; Find It, with Jeff Hogan</a>.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Stay tuned for more, and we'll add some new resources (scripts and checklists, for example) to the links as they become available!Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah004---data-fiduciary-responsibility-and-reversing-trend-with-jeff-hogan" target="_blank">AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan</a></li><li><a href="https://www.cap-rx.com/insights/the-consolidated-appropriations-act-prescription-drug-data-collection-rxdc-new-rules-regulations-equal-new-responsibilities" target="_blank">The Consolidated Appropriations Act &amp; Prescription Drug Data Collection (RxDC): New Rules &amp; Regulations Equal New Responsibilities</a></li><li><a href="https://www.cap-rx.com/insights/self-funded-plans-ignore-the-consolidated-appropriations-act-at-their-peril" target="_blank">Self-funded plans ignore the Consolidated Appropriations Act at their peril</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, three experts weigh in on rising litigation against employers and pharmacy benefit managers (PBMs) and what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.

AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, four women pharmacists across Capital Rx's teams join host Justin Venneri to celebrate #WPD2024! Amy Stockton, PharmD (our guest for Episode 6); Symara Schmidt, PharmD, BCGP; Lauren Carroll, PharmD, BCACP; and Marissa Miller, PharmD, discuss the significance of Women Pharmacist Day and highlight the progress women have made in the pharmacy field and how and why they are celebrating this unique holiday within American Pharmacists Month. The conversation highlights personal stories about their careers, including advice they'd share with their younger selves, how they balance their roles at work and home, the importance of mentoring the next generation of women pharmacists, the impact pharmacists have on patient care, and their hopes for the future!Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah006---pharmacy-benefits-101-clinical-care-teams-with-amy-stockton-pharmd" target="_blank">AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/ah025---empowering-pharmacists-with-naspas-krystalyn-weaver-pharmd-jd" target="_blank">AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, four women pharmacists across Capital Rx's teams join host Justin Venneri to celebrate #WPD2024! Amy Stockton, PharmD (our guest for Episode 6); Symara Schmidt, PharmD, BCGP; Lauren Carroll, PharmD, BCACP; and Marissa Miller, PharmD, discuss the significance of Women Pharmacist Day and highlight the progress women have made in the pharmacy field and how and why they are celebrating this unique holiday within American Pharmacists Month.

AH040 - Celebrating Women Pharmacist Day 2024

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Capital Rx's Samantha Custer, Director of Member Experience, and Jake Mulkey, Product Manager, join host Justin Venneri to discuss a niche, important aspect of Medicare Part D plans: Transition Benefits. What goes on behind the scenes to enable a plan member to receive uninterrupted care? What role does modern software - i.e., <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> - play in providing members with a temporary supply of their medication and meeting notification requirements? What makes for a great relationship between product teams and other business units?To answer these questions and more, Sam and Jake explain everything from how processes can be built into the adjudication process in JUDI in real time to the exchange of data and reporting surrounding the notifications that must be sent to plan members, per CMS requirements. Sam also explains how flexible JUDI is and that if CMS issues changes to any one part of the process, they can be adhered to "quickly and easily," or if commercial clients want to leverage the setup, it's no problem. Jake shares his views on building products in a modern platform and some things he's learned over the years that make for a good working relationship between product and other teams.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah005---star-ratings-mtm-cms-translation-requirements-with-jay-tran-pharmd" target="_blank">AH005 - Star Ratings, MTM, &amp; CMS Translation Requirements with Jay Tran, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-medicare-star-ratings" target="_blank">Pharmacy Benefits 101: Medicare Star Ratings</a><a href="https://www.cap-rx.com/insights/our-favorite-features-added-to-judi-r-in-2023" target="_blank">‍</a></li><li><a href="https://www.cap-rx.com/insights/our-favorite-features-added-to-judi-r-in-2023" target="_blank">How Our Favorite New JUDI® Features Aid Pharmacy Benefit Administration</a></li><li><a href="https://www.cap-rx.com/insights/how-our-favorite-new-judi-r-features-aid-government-programs" target="_blank">How Our Favorite New JUDI® Features Aid Government Programs</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, Capital Rx's Samantha Custer, Director of Member Experience, and Jake Mulkey, Product Manager, join host Justin Venneri to discuss a niche, important aspect of Medicare Part D plans: Transition Benefits. What goes on behind the scenes to enable a plan member to receive uninterrupted care? What role does modern software - i.e., JUDI® - play in providing members with a temporary supply of their medication and meeting notification requirements? What makes for a great relationship between product teams and other business units? Sam and Jake answer these questions and more on Episode 39.

AH039 - Transition Benefits and the Relationship Between Communications and Product Management

In Episode 38 of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Formulary Operations Manager Libbi Green, PharmD, joins host Justin Venneri in the studio for a timely discussion about flu season. The conversation covers the background of flu season, this year's flu vaccines, the timing and importance of vaccinations, how the flu vaccine performed last season, predicting flu trends, and the availability of different vaccine formulations to accommodate patients' varying needs.Libbi also explains the role of pharmacies and healthcare providers in administering flu shots, emphasizing the importance of accessibility and preventing serious illness and hospitalizations, what's important for plan sponsors to consider for their populations, the vaccine production schedule, and what advancements we may be able to look forward to!Related Content/Articles<ul><li><a href="https://www.pharmacytimes.com/view/research-results-show-promise-toward-development-of-a-universal-influenza-vaccine" target="_blank">Research Results Show Promise Toward Development of a Universal Influenza Vaccine </a>(Pharmacy Times; July 2024)</li><li><a href="https://www.cap-rx.com/insights/next-generation-vaccines-and-therapies-for-seasonal-influenza" target="_blank">Next-Generation Vaccines and Therapies for Seasonal Influenza</a></li><li><a href="https://www.cap-rx.com/insights/impact-of-the-inflation-reduction-act-on-vaccinations-what-pharmacists-need-to-know" target="_blank">Impact of the Inflation Reduction Act on Vaccinations: What Pharmacists Need to Know</a></li></ul>Helpful Resources<ul><li><a href="https://www.cdc.gov/fluview/" target="_blank">CDC Flu View - Weekly U.S. Influenza Surveillance Report</a></li><li><a href="https://www.cdc.gov/flu/about/season.html" target="_blank">CDC - What to Know About Flu Season</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In Episode 38 of the Astonishing Healthcare podcast, Formulary Operations Manager Libbi Green, PharmD, joins host Justin Venneri in the studio for a timely discussion about flu season. The conversation covers the background of flu season, this year's flu vaccines, the timing and importance of vaccinations, how the flu vaccine performed last season, predicting flu trends, and the availability of different vaccine formulations to accommodate patients' varying needs.

AH038 - Navigating Flu Season! A Quick Update on Vaccines and Such, with Libbi Green, PharmD

On this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Kevin Sundquist, VP of Product at Capital Rx, joins host Justin Venneri to discuss the journey of a pharmacy claim, from the prescription at the doctor's office to the pharmacy counter. Kevin explains how <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> allows claims to be processed efficiently and transparently and why benefit design, network selections, and utilization management programs such as prior authorization ultimately dictate how easy it is for plan members to fill their prescriptions at their local pharmacies or through the mail. Kevin aims to help people find the best prices and live healthier lives.AH037 builds on Episodes <a href="https://www.cap-rx.com/insights/ah027---what-is-pharmacy-benefit-management-with-jillian-lonson-and-jean-beman-part-1" target="_blank">AH027</a> and <a href="https://www.cap-rx.com/insights/ah028---what-is-pharmacy-benefit-management-with-jillian-lonson-and-jean-beman-part-2" target="_blank">AH028</a> with Jillian Lonson, PMP®, Sr. Director, Benefits Administration &amp; Operations, and Jean Beman, Manager, Benefits Operations &amp; Administration - our two-part What is Pharmacy Benefit Management? series that describes the importance of benefit design and configuration, as well as his webinar, <a href="https://www.cap-rx.com/insights/replay---the-story-of-a-claim" target="_blank">The Story of a Claim</a>. If you've ever wondered how products are developed and processes and workflows are refined to ensure medications reach patients smoothly and affordably or what a future with unified claims looks like, this episode is for you!Related Content<ul><li><a href="https://www.cap-rx.com/insights/replay-the-future-of-claims-processing-a-deep-dive-into-a-modern-adjudication-system" target="_blank">Replay – The Future of Pharmacy Claims Processing: A Deep Dive into a Modern Adjudication System</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-prior-authorizations" target="_blank">Pharmacy Benefits 101: Prior Authorizations</a></li><li><a href="https://www.cap-rx.com/insights/our-favorite-features-added-to-judi-r-in-2023" target="_blank">How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

On this episode of the Astonishing Healthcare podcast, Kevin Sunquist, VP of Product at Capital Rx, joins host Justin Venneri to discuss the journey of a pharmacy claim, from the prescription at the doctor's office to the pharmacy counter. Kevin explains how JUDI® allows claims to be processed efficiently and transparently and why benefit design, network selections, and utilization management programs such as prior authorization ultimately dictate how easy it is for plan members to fill their prescriptions at their local pharmacies or through the mail.

AH037 - The Story of a Claim: Redefining the Benefit Experience, with Kevin Sundquist

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Joe Murad, CEO of Vida Health, joins host Justin Venneri and Capital Rx Chief Clinical Officer Sara Izadi, PharmD, in the studio for a discussion about glucagon-like peptide-1 (of GLP-1) medications and how partnering to manage cardiometabolic health can help plan sponsors control costs and keep their populations healthy. Joe and Sara review the latest data, including the rising prevalence of obesity and diabetes, GLP-1 discontinuation rates, the robust GLP-1 pipeline, and they highlight the <a href="Capital Rx and Vida Health Partner to Launch Rx Activate, a High-Touch Chronic Condition Management Program" target="_blank">innovative partnership between Capital Rx and Vida</a>. Together, they explore the importance of appropriate patient management, education, and support, nuances of GLP-1 prescribing like dose titration, the role of digital health technology in achieving effective healthcare outcomes and coordinating care with other providers, and what to watch for in 2025.Related Content<ul><li><a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a></li><li><a href="https://www.cap-rx.com/insights/ah021---managing-pharmacy-costs-in-a-glp-1-world-with-bridget-mulvenna" target="_blank">AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna</a></li><li><a href="https://www.cap-rx.com/insights/glp-1s-are-no-laughing-matter" target="_blank">GLP-1s are No Laughing Matter</a></li></ul>Sources<ul><li><a href="https://www.healthsystemtracker.org/brief/how-many-adults-with-private-health-insurance-could-use-glp-1-drugs/" target="_blank">How many adults with private health insurance could use GLP-1 drugs</a> (KFF; 9/5)</li><li><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819256" target="_blank">GLP-1 Receptor Agonist Discontinuation Among Patients With Obesity and/or Type 2 Diabetes</a> (JAMA; 5/24)</li><li><a href="https://www.kff.org/health-costs/press-release/poll-1-in-8-adults-say-theyve-taken-a-glp-1-drug-including-4-in-10-of-those-with-diabetes-and-1-in-4-of-those-with-heart-disease/" target="_blank">Poll: 1 in 8 Adults Say They’ve Taken a GLP-1 Drug, Including 4 in 10 of Those with Diabetes and 1 in 4 of Those with Heart Disease</a> (KFF; 5/10)</li><li><a href="https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-use-of-medicines-in-the-us-2024" target="_blank">The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028</a> (IQVIA; 5/7)</li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, Joe Murad, CEO of Vida Health, joins host Justin Venneri and Capital Rx Chief Clinical Officer Sara Izadi, PharmD, in the studio for a discussion about glucagon-like peptide-1 (of GLP-1) medications and how partnering to manage cardiometabolic health can help plan sponsors control costs and keep their populations healthy.  Joe and Sara review the latest data, including the rising prevalence of obesity and diabetes, GLP-1 discontinuation rates, the robust GLP-1 pipeline, and they highlight the innovative partnership between Capital Rx and Vida.

AH036 - The Rise of GLP-1s & Partnering to Manage Chronic Diseases, with Vida Health

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Justin Venneri speaks with Bonnie Hui-Callahan, PharmD, CDCES, Senior Director of Clinical Programs at Capital Rx, about the significance of clinical programs within the pharmacy benefit management (PBM) space. Bonnie explains how clinical programs serve as an "added layer of service" similar to after-school programs. They enhance the core functions of PBMs (claim administration) and help plan sponsors reduce costs, improve quality of care, enhance patient safety, and address prevalent health conditions within their populations.The conversation delves into the different types of clinical programs offered by Capital Rx, categorized into five key areas: utilization management, cost containment, patient safety, population health, and personalized care. Bonnie emphasizes that while many programs, such as opioid safety and medication therapy management, are standard across PBMs, there are also unique, in-house, and vendor-partnered solutions tailored to specific health conditions. She also highlights the potential benefits and importance of integrating pharmacy and medical claims, offers some key questions plan fiduciaries can ask, and reviews the results of a recent poster presentation by her team at the 2024 Pharmacy Quality Alliance meeting!Related Content<ul><li><a href="https://www.cap-rx.com/insights/impact-of-point-of-sale-duplicate-therapy-safety-alert-on-concomitant-dpp-4-inhibitor-and-glp-1-agonist-use-poster" target="_blank">Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use</a></li><li><a href="https://www.cap-rx.com/insights/ah005---star-ratings-mtm-cms-translation-requirements-with-jay-tran-pharmd" target="_blank">AH005 - Star Ratings, MTM, &amp; CMS Translation Requirements with Jay Tran, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/ah006---pharmacy-benefits-101-clinical-care-teams-with-amy-stockton-pharmd" target="_blank">AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-prior-authorizations" target="_blank">Pharmacy Benefits 101: Prior Authorizations</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, Justin Venneri speaks with Bonnie Hui-Callahan, PharmD, CDCES, Senior Director of Clinical Programs at Capital Rx, about the significance of clinical programs within the pharmacy benefit management (PBM) space. Bonnie explains how clinical programs serve as an "added layer of service" similar to after-school programs. They enhance the core functions of PBMs (claim administration) and help plan sponsors reduce costs, improve quality of care, enhance patient safety, and address prevalent health conditions within their populations.

AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Will Tafoya, Senior Vice President of Operations and the leader of Capital Rx's contact center, shares his views on building and leading an <a href="https://www.cap-rx.com/insights/capital-rxs-customer-care-team-wins-5-stevie-r-awards-for-customer-service" target="_blank">award-winning</a> customer care team, which is available 24/7/365 to serve millions of pharmacy plan members. Will's passion for customer care and his team shines through, as he explains why hiring PTCB pharmacy technicians and other individuals with healthcare experience is so important, the benefits of a virtual call center (vs. brick-and-mortar), how customer care interfaces with clinical or other teams, and much more.Since member service and support are central to Capital Rx's new <a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">Never Move Again™</a>, as as AJ Loiacono describes in <a href="https://www.cap-rx.com/insights/ah033---never-move-again-tm-a-paradigm-shift-in-pharmacy-benefits-with-aj-loiacono" target="_blank">Episode 33 - </a><a href="https://www.cap-rx.com/insights/ah033---never-move-again-tm-a-paradigm-shift-in-pharmacy-benefits-with-aj-loiacono" target="_blank">Never Move Again™</a><a href="https://www.cap-rx.com/insights/ah033---never-move-again-tm-a-paradigm-shift-in-pharmacy-benefits-with-aj-loiacono" target="_blank">, a Paradigm Shift in Pharmacy Benefits</a>, Will and host Justin Venneri dive into topics including:<ul><li>Client-specific training (e.g., cultural training)</li><li>Why JUDI®, Capital Rx's enterprise health platform, is a "one-stop-shop" for Will's team</li><li>The importance of considering how members will react to AI and automation</li><li>Measures of success, including average speed of answer (ASA) and handle time</li></ul>Finally, Will shares that advice that's been most influential to him over his 30+ years in contact center leadership. (Hint: it's something we should never stop doing!)For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, Will Tafoya, Senior Vice President of Operations and the leader of Capital Rx's contact center, shares his views on building and leading Capital Rx's award-winning customer care team, which is available 24/7/365 to serve millions of pharmacy plan members. Will's passion for customer care and his team shines through, as he explains why hiring PTCB pharmacy technicians and other individuals with healthcare experience is so important, the benefits of a virtual call center (vs. brick-and-mortar), how customer care interfaces with clinical or other teams, and much more.

AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will Tafoya

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, AJ Loiacono, co-founder &amp; CEO of Capital Rx, joins Justin Venneri to discuss Never Move Again™, the recently launched "unbundled" pharmacy benefit administration solution for large employers. It turns out larger employer groups, TPAs, and other groups with 50,000+ lives are very similar to health plans, which value the flexibility and transparency an unconflicted administrator provides. Supported by JUDI®, our single scalable enterprise health platform and a world-class call center, plan fiduciaries now have an option that addresses the pain points of CAA compliance and the friction of switching PBMs over time.<ul><li>The program's transparent, flat-fee structure ensures no incentive to push more expensive drugs, leverage hidden markups, or otherwise profit at the plan's expense - aligning with the fiduciary duties under ERISA.</li><li>JUDI Health is the solution's core, providing a fully integrated system that allows clients to use their preferred services - point solutions, other vendors, rebate aggregators, or even pharmacy network options.</li><li>Never Move Again™ is a return to the original, independent role of PBMs, offering a more ethical and efficient future for U.S. healthcare.</li></ul>Additionally, and please forgive the shameless plug, AJ joined Josh Golden, SVP of Strategy here at Capital Rx, who we spoke with earlier this year about future-proofing your pharmacy benefit plan (<a href="https://www.cap-rx.com/insights/ah008---ask-the-right-questions-to-future-proof-your-pharmacy-benefit-plan-with-josh-golden" target="_blank">AH008</a>), on September 19, 2024, at 2:00 PM ET for an educational webinar explaining our new offering: <a href="https://www.cap-rx.com/insights/replay---build-a-lasting-pharmacy-benefit-strategy-with-never-move-again-tm" target="_blank">Build a Lasting Pharmacy Benefit Strategy with </a><a href="https://capitalrx.zoom.us/webinar/register/1917235704905/WN_6-0JWkJ9R0mlBok_q47rDw" target="_blank">Never Move Again™</a>.Related Content<ul><li><a href="https://www.cap-rx.com/insights/capital-rx-launches-never-move-again-tm-enabling-self-funded-plan-sponsors-to-perpetually-access-the-best-drug-prices-without-ever-having-to-reimplement-a-plan-reissue-cards-or-expose-members-to-unnecessary-disruption" target="_blank">Capital Rx Launches Never Move Again™, Enabling Self-Funded Plan Sponsors to Perpetually Access the Best Drug Prices Without Ever Having to Reimplement a Plan</a></li><li><a href="https://www.cap-rx.com/insights/vive-2023-whats-behind-the-price-tag-of-medication-highlights#:~:text=Pharmacy%20Benefit%20Management%20(PBM)%3A%C2%A0The%20Coming%20Divide%20Between%20Administration%20%26%C2%A0Fulfillment" target="_blank">ViVE 2023 Highlights: What's Behind the Price Tag of Medication</a></li><li><a href="https://www.cap-rx.com/insights/ah032---prescription-rebates-agreements-guarantees-and-more-with-npcs-john-obrien-pharmd-mph-and-julie-patterson-pharmd-phd" target="_blank">AH032 - Prescription Rebates: Agreements, Guarantees, and More, with NPC's John O'Brien, PharmD, MPH, and Julie Patterson, PharmD, PhD</a></li></ul>Learn more about <a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">Never Move Again™ </a><a href="https://www.cap-rx.com/solutions/unbundle-pharmacy-benefits-management" target="_blank">HERE</a>.For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, AJ Loiacono, co-founder & CEO of Capital Rx, joins Justin Venneri to discuss Never Move Again™, the recently launched "unbundled" pharmacy benefit administration solution for large employers. It turns out larger employer groups, TPAs, and other groups with 50,000+ lives are very similar to health plans, which value the flexibility and transparency an unconflicted administrator provides. Supported by JUDI®, our single scalable enterprise health platform and a world-class call center, plan fiduciaries now have an option that addresses the pain points of CAA compliance and the friction of switching PBMs over time.

AH033 – Never Move Again™, a Paradigm Shift in Pharmacy Benefits, with AJ Loiacono

In this episode of the Astonishing Healthcare podcast, we dive into the National Pharmaceutical Council's recent employer survey on rebates and rebate guarantees published in the AJMC, <a href="https://www.ajmc.com/view/prescription-rebate-guarantees-employer-insights" target="_blank">Prescription Rebate Guarantees: Employer Insights</a> ((7/19/24). NPC CEO John O'Brien, PharmD, MPH, and Senior Research Director Julie Patterson, PharmD, PhD joined Capital Rx's Co-Founder and CEO AJ Loiacono in the studio for the discussion, which covered everything from how and why rebates have become so important to employers and traditional PBMs and what "pass-through" means to "the spreadsheet" and the difficulty in comparing traditional and more modern PBMs and how rebates impact a plan's net total cost.AJ and John highlight how PBMs manipulate drug prices through rebate incentives, resulting in higher costs for employers and patients, and Julie reviews the results of their survey, explaining why employers must "break the addiction to rebates." They emphasize the importance of transparency and the role of employer benefits consultants in PBM procurement and evaluation as well (at Capital Rx, we value objective, helpful advice on benefit design for our employees). Check out the survey and be sure to sign up for NPC's newsletter to follow their work - it sounds like there's a lot more to follow!Contact Information<ul><li>Sign up for the NPC This Week Newsletter: <a href="https://url.usb.m.mimecastprotect.com/s/av9eCDwKKnC51Ky4UZs1uz2Rs3?domain=npcnow.org" target="_blank">https://www.npcnow.org/subscribe-updates</a></li><li>Check out the <a href="https://www.linkedin.com/company/national-pharmaceutical-council/" target="_blank">National Pharmaceutical Council on LinkedIn</a></li><li>Connect with <a href="https://www.linkedin.com/in/drjmob/" target="_blank">John O’Brien, PharmD, MPH on LinkedIn</a></li><li>Connect with <a href="https://www.linkedin.com/in/julie-patterson-67641062/" target="_blank">Julie Patterson, PharmD, PhD on LinkedIn</a></li></ul>Related Content<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-pharmaceutical-rebates" target="_blank">Pharmacy Benefits 101: Pharmaceutical Rebates</a></li><li><a href="https://www.cap-rx.com/insights/ah002---a-former-pharmacy-program-directors-view-on-controlling-pharmacy-costs" target="_blank">AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs</a></li><li><a href="https://www.cap-rx.com/insights/our-clearinghouse-model-r-pharma-revenue-explained" target="_blank">Our Single-Ledger Model™ - Pharma Revenue Explained</a></li></ul>Visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for this episode's transcript and additional content!

In this episode of the Astonishing Healthcare podcast, we dive into the National Pharmaceutical Council's recent employer survey on rebates and rebate guarantees published in the AJMC, Prescription Rebate Guarantees: Employer Insights ((7/19/24). NPC CEO John O'Brien, PharmD, MPH, and Senior Research Director Julie Patterson, PharmD, PhD joined Capital Rx's Co-Founder and CEO AJ Loiacono in the studio for the discussion, which covered everything from how and why rebates have become so important to employers and traditional PBMs and what "pass-through" means to "the spreadsheet" and the difficulty in comparing traditional and more modern PBMs and how rebates impact a plan's net total cost.

AH032 - Prescription Rebates: Agreements, Guarantees, and More, with NPC's John O'Brien, PharmD, MPH, and Julie Patterson, PharmD, PhD

In this episode of the Astonishing Healthcare podcast, Justin Venneri sits down with <a href="https://www.cap-rx.com/team/kristin-begley" target="_blank">Kristen Begley, PharmD</a>, Chief Commercial Officer, and <a href="https://www.cap-rx.com/team/michael-miele" target="_blank">Michael Miele, FSA, MAAA</a>, Senior Vice President of Insured Services, for a discussion about some of the finer points of pharmacy benefit management (PBM) procurement and pharmacy program cost evaluation, including how misaligned incentives can drive costs higher than they should be for plan sponsors. They delve into the misleading nature of focusing on unit costs and high rebates and advocate for a per member per month (PMPM) model to gain a clearer picture of true costs and hold PBMs accountable.Kristin and Mike suggest ways to update and improve legacy PBM evaluation methods, encouraging stakeholders to more carefully consider everything from the questionnaires leveraged to screen potential PBM partners to the true value of clinical programs for utilization management - such as prior authorization - and the actual number of units used to forecast spending.Related PMPM Content:<ul><li><a href="https://www.cap-rx.com/insights/ah010---the-power-of-pmpm-holding-pbms-accountable-for-total-drug-spend-with-kristin-begley-pharmd" target="_blank">AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/pmpm-is-it-the-best-way-to-measure-or-track-anything" target="_blank">PMPM - Is It the Best Way to Measure or Track Anything?</a></li><li><a href="https://www.cap-rx.com/insights/pbm-procurement-a-pmpm-guide-for-plans-sponsors-ebook" target="_blank">PBM Procurement: A PMPM Guide for Plans Sponsors eBook</a></li></ul>Visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for this episode's transcript and additional content!

In this episode of the Astonishing Healthcare podcast, Justin Venneri sits down with Kristen Begley, PharmD, Chief Commercial Officer, and Michael Miele, FSA, MAAA, Senior Vice President of Insured Services for a discussion about some of the finer points of pharmacy benefit management (PBM) procurement and pharmacy program cost evaluation, including how misaligned incentives can drive costs higher than they should be for plan sponsors. They delve into the misleading nature of focusing on unit costs and high rebates and advocate for a per member per month (PMPM) model to gain a clearer picture of true costs and hold PBMs accountable.

AH031 - Dissecting Pharmacy Cost Drivers and the Value of PMPM, with Kristin Begley, PharmD, and Mike Miele FSA, MAAA

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank">Astonishing Healthcare podcast</a>, Jeffrey Hogan, President of Upside Health Advisors, returns to the show for a timely discussion with Justin Venneri about why the timing is perfect for health plan sponsors and fiduciaries to engage their partners to secure necessary disclosure requirements and access to their data: it's renewal season! The Consolidated Appropriations Act (CAA) placed additional responsibilities on plan fiduciaries, including the need to make attestations. With gag clauses removed from contracts, the door is open. Jeff stresses the importance of analyzing the plan's data to make informed decisions and meet the fiduciary obligations. "The industry is craving trust," and fiduciaries need a trusted source of data and analytics to help them identify areas of waste and make changes that will benefit their plans. Whether it's pharmacy benefits, hospital spend, or the commissions paid to brokers/consultants, there's a unique opportunity to gain the insight needed and avoid the rising risk of liability right now.To learn more about Upside Health Advisors, <a href="https://theupsideeffect.com/contact-us" target="_blank">click here,</a> or you can find Jeff on <a href="https://www.linkedin.com/in/jeffhogan06/" target="_blank">LinkedIn</a>.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah004---data-fiduciary-responsibility-and-reversing-trend-with-jeff-hogan" target="_blank">AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan</a></li><li><a href="https://www.cap-rx.com/insights/the-consolidated-appropriations-act-prescription-drug-data-collection-rxdc-new-rules-regulations-equal-new-responsibilities" target="_blank">The Consolidated Appropriations Act &amp; Prescription Drug Data Collection (RxDC): New Rules &amp; Regulations Equal New Responsibilities</a></li><li><a href="https://www.cap-rx.com/insights/self-funded-plans-ignore-the-consolidated-appropriations-act-at-their-peril" target="_blank">Self-funded plans ignore the Consolidated Appropriations Act at their peril</a></li></ul>For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare podcast, Jeffrey Hogan, President of Upside Health Advisors, returns to the show for a timely discussion with Justin Venneri  about why the timing is perfect for health plan sponsors and fiduciaries to engage their partners to secure necessary disclosure requirements and access to their data: it's renewal season!

AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan

In this episode of the Astonishing Healthcare podcast, Nick Van Hook (VP, Commercial Markets) joins host Justin Venneri to discuss the pharmacy benefits selling season and the importance of building relationships and trust in B2B sales, especially in healthcare. They start with Nick's career journey - from pursuing a professional golf career and not knowing what a pharmacy benefit manager (PBM) is to consulting and, ultimately, Capital Rx - and then dive into the top questions and issues Nick fields and must address while building personal connections and closing deals with larger employers, including health systems and universities, where he tends to focus his time.Nick shares his insights on current market trends, such as the significant impact specialty drugs and GLP-1s are having on employers' overall plan spend. He also explains drug mix and how Capital Rx differentiates itself by leveraging <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> to maintain independence and administer aligned pharmacy benefit programs that meet clients' needs without the conflicts of interest that arise from owning dispensing assets and engaging in spread pricing., for example.Related Content:<ul><li><a href="https://www.cap-rx.com/insights/the-upside-of-a-single-ledger-model-tm-in-pharmacy-benefits" target="_blank">The Upside of a Single-Ledger Model™ in Pharmacy Benefits</a></li><li><a href="https://www.cap-rx.com/insights/ah010---the-power-of-pmpm-holding-pbms-accountable-for-total-drug-spend-with-kristin-begley-pharmd" target="_blank">AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD</a></li><li><a href="https://www.cap-rx.com/insights/ah021---managing-pharmacy-costs-in-a-glp-1-world-with-bridget-mulvenna" target="_blank">AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna</a> &amp; <a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a> (Blog)</li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Nick Van Hook (VP, Commercial Markets) joins host Justin Venneri to discuss the pharmacy benefits selling season and the importance of building relationships and trust in B2B sales. They discuss Nick's career journey - from pursuing a professional golf career and not knowing what a pharmacy benefit manager (PBM) is to consulting and, ultimately, Capital Rx - as well as the top questions and issues Nick fields and must address while building personal connections and closing deals with larger employers, including health systems and universities, where he tends to focus his time.

AH029 - Selling Pharmacy Benefits: Building Relationships & Meeting Clients' Needs, with Nick Van Hook

In this Part 2 episode of Astonishing Healthcare, Justin Venneri continues the discussion about what a pharmacy benefit manager (PBM) does with Capital Rx team members Jillian Lonson, PMP®, Sr. Director, Benefits Administration &amp; Operations, and Jean Beman, Manager, Benefits Operations &amp; Administration. They dive deeper into the weeds and geek out on topics including benefit configuration, enhancements, and testing to be sure everything is set up correctly! They also explain how <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> is different and makes several aspects of the process far simpler than they've experienced in the past with legacy software solutions.Jillian and Jean also share their perspectives on the common challenges employers, for example, face when configuring and implementing a new PBM. They offer advice to ensure things go smoothly, emphasizing the importance of considering member experience. Last, Jean explains how JUDI's design enables the deployment of enhancements such as a new <a href="https://www.cap-rx.com/solutions/medicare-prescription-payment-plan" target="_blank">Medicare Prescription Payment Plan (M3P)</a> solutions with relative ease.Related Content:<ul><li><a href="https://www.cap-rx.com/insights/ah027---what-is-pharmacy-benefit-management-with-jillian-lonson-and-jean-beman-part-1" target="_blank">AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1</a></li><li><a href="https://www.cap-rx.com/insights/government-programs-the-true-meaning-of-customization" target="_blank">Government Programs: The True Meaning of Customization </a>(with Jason Barretto)</li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-successful-implementations" target="_blank">Pharmacy Benefits 101: Successful Implementations</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this Part 2 episode of Astonishing Healthcare, Justin Venneri continues the discussion about what a pharmacy benefit manager (PBM) does with Capital Rx team members Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration. They dive deeper into the weeds and geek out on topics including benefit configuration, enhancements, and testing to be sure everything is set up correctly! They also explain how JUDI® is different and makes several aspects of the process far simpler than they've experienced in the past with legacy software solutions.

AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2

In this episode of the Astonishing Healthcare podcast, Jillian Lonson, PMP®, Sr. Director, Benefits Administration &amp; Operations, and Jean Beman, Manager, Benefits Operations &amp; Administration, join host Justin Venneri for part one of a two-part discussion about what pharmacy benefit management (PBM) entails. They describe the basics and then peel back the layers of what PBMs do to ensure that a prescription processes correctly - per your pharmacy benefit - so you can pay the correct amount at the pharmacy counter or receive your medication in the mail.Jillian and Jean also share their professional journeys within the PBM industry, highlighting how their roles and teams are central to configuring and testing plan benefits so that formularies, the network, and clinical programs are set up correctly. This informative episode sets the table for a deeper dive into the configuration and testing that go on behind the scenes!Related Content:<ul><li><a href="https://www.cap-rx.com/insights/ah001---building-a-pbm-tech-navigating-growth-and-delivering-value-with-aj-loiacono" target="_blank">AH001 - Building a PBM: Tech, Navigating Growth, and Delivering Value with AJ Loiacono</a></li><li><a href="https://www.cap-rx.com/insights/what-is-the-role-of-a-pharmacy-benefits-manager-pbm" target="_blank">What Is the Role of a Pharmacy Benefits Manager (PBM)?</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-what-is-a-formulary" target="_blank">Pharmacy Benefits 101: What is a Formulary?</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration, join host Justin Venneri for part 1 of a two-part discussion about what pharmacy benefit management (PBM) entails. They describe the basics and then peel back the layers of what PBMs do to ensure that a medication processes correctly for your pharmacy benefit so you can pay the correct amount at the pharmacy counter or receive your medication in the mail.

AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1

In this episode of Astonishing Healthcare, Alfonso Martinez, Director of Product Management at Capital Rx, joins Justin Venneri to discuss the transformative role APIs - application programming interfaces - play in the healthcare industry and the flexibility they offer plan sponsors and benefits administrators to be imaginative. He explains how APIs facilitate seamless integration, automate critical workflows, and empower real-time data access and exchange, significantly enhancing user experiences.Alfonso reviews several practical use cases and explains how an open platform like <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a> is revolutionizing pharmacy benefits management without being too "salesy." Additionally, they touch upon the future potential of APIs in achieving value-based care by breaking down data silos and enabling integrated analytics, processing payments, and much more!Related Content<ul><li><a href="https://www.cap-rx.com/insights/capital-rxs-judi-r-the-beauty-of-an-open-platform" target="_blank">Capital Rx’s JUDI® - The Beauty of an Open Platform</a></li><li><a href="https://www.cap-rx.com/insights/capital-rxs-enterprise-health-platform-enables-healthcare-organizations-to-meet-the-centers-for-medicare-medicaid-services-m3p-requirements" target="_blank">Capital Rx’s Enterprise Health Platform Enables Healthcare Organizations to Meet The CENTERS for MEDICARE &amp; MEDICAID SERVICES’ M3P Requirements</a></li><li><a href="https://www.cap-rx.com/insights/ah007---theres-no-value-based-care-without-considering-pharmacy-with-sunil-budhrani-md" target="_blank">AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of Astonishing Healthcare, Alfonso Martinez joins Justin Venneri to discuss the transformative role APIs - application programming interfaces - play in the healthcare industry and the flexibility they offer plan sponsors and benefits administrators to be imaginative. He explains how APIs facilitate seamless integration, automate critical workflows, and empower real-time data access and exchange, significantly enhancing user experiences.

AH026 - The Power of APIs in Healthcare, with Alfonso Martinez

Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA), Krystalyn Weaver, PharmD, JD, joins host Justin Venneri for a discussion about pharmacists and expanding their scope of practice. She shares her insights on the role pharmacists can play in the healthcare system and highlights several positive developments recently, including Iowa changing the scope of practice to be a standard of care model and Tennessee passing a law that allows pharmacists to prescribe in a "slew of categories" without requiring additional regulations.Additionally, Krystalyn shares her thoughts on the importance of making progress at the federal level to allow pharmacists to be reimbursed by Medicare (<a href="https://www.pharmacist.com/Advocacy/Issues/Provider-Status/Equitable-Community-Access-to-Pharmacist-Services-Act-ECAPS" target="_blank">ECAPS</a>), the AMA's stance against the expansion of pharmacists' responsibilities, how to relieve the pressure on the pharmacy business model, what some pharmacies are doing to diversify their businesses and succeed, and much more.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah023---compliance-matters-with-heidi-mckinnon-pharmd-chc" target="_blank">AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC</a></li><li><a href="https://ncpa.org/newsroom/qam/2024/04/22/iowa-governor-signs-legislation-modernizes-state-pharmacy-practice-act" target="_blank">Iowa governor signs legislation that modernizes the state Pharmacy Practice Act</a></li><li><a href="https://www.pharmacist.com/Pharmacy-News/under-new-law-pharmacist-scope-of-practice-expands-in-tennessee" target="_blank">Under new law, pharmacist scope of practice expands in Tennessee</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA), Krystalyn Weaver, PharmD, JD, joins host Justin Venneri for a discussion about pharmacists and expanding their scope of practice. She shares her insights on the role pharmacists can play in the healthcare system and highlights several positive developments recently, including Iowa changing the scope of practice to be a standard of care model and Tennessee passing a law that allows pharmacists to prescribe in a "slew of categories" without requiring additional regulations.

AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD

We dedicated this episode of Astonishing Healthcare to discussing the ongoing challenges within the pharmacy benefit management (PBM) industry, as unveiled by a recent front-page <a href="https://www.nytimes.com/2024/06/21/business/prescription-drug-costs-pbm.html" target="_blank">New York Times article</a> (subscription required). Capital Rx Senior Vice Presidents Josh Golden and Ryan Duffy join host Justin Venneri to share their reactions to the article and opinions about where the spotlight should be at this time. The article brings several issues to the forefront, including new "layers" of profit opportunity for traditional PBMs, which come at the expense of health plans/payers.Ryan and Josh also stress the importance of PBM transparency and alignment with plan sponsors' (and members') interests. They also explain why HR leaders and benefits administrators must be vigilant and prepared for a shift toward more accountable PBM models. Potential regulatory reforms and their implications are also examined, providing insights into how to navigate and optimize pharmacy benefit management in today's complex healthcare landscape.Related Content<ul><li><a href="https://www.cap-rx.com/insights/ah015---pbm-legislation-contracting-and-more-with-lloyd-fiorini" target="_blank">AH015 - PBM Legislation, Contracting, and More, with Lloyd Fiorini</a></li><li><a href="https://www.cap-rx.com/insights/5-ways-to-improve-your-pbm-procurement-process-in-2024" target="_blank">5 ways to improve your PBM procurement process in 2024</a></li><li><a href="https://www.cap-rx.com/insights/your-pbm-is-the-problem" target="_blank">Your PBM is the Problem</a></li><li><a href="https://www.cap-rx.com/insights/capital-rx-ceo-pbm-industry-needs-to-be-repaired-not-ditched" target="_blank">Capital Rx CEO: PBM industry needs to be repaired, not ditched</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

We dedicated this episode of Astonishing Healthcare to discussing the ongoing challenges within the pharmacy benefit management (PBM) industry, as unveiled by a recent front-page New York Times article (subscription required). Capital Rx Senior Vice Presidents Josh Golden and Ryan Duffy join host Justin Venneri to share their reactions to the article and opinions about where the spotlight should be at this time. The article brings several issues to the forefront, including new "layers" of profit opportunity for traditional PBMs, which come at the expense of health plans/payers.

AH024 - PBMs in the News, Again, with Ryan Duffy and Josh Golden

On this episode of the Astonishing Healthcare podcast, Capital Rx's head of compliance, Heidi McKinnon, PharmD, CHC, joins Justin Venneri for a discussion about a few of the critical issues she's tracking today that are either currently impacting or could impact the pharmacy benefits industry. With over 20 years of experience, she expertly navigates topics like the role of AI in detecting fraud, risks associated with compounding GLP-1 medications, and the nuances of digital pharmacy operations (vs. retail or mail order). Heidi underscores the need for a sound compliance framework to support business growth and meet evolving regulatory requirements. She also explains the importance of relaying the "compliance is a good thing" message from the top down.Related Content<ul><li><a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a></li><li><a href="https://www.cap-rx.com/insights/ah021---managing-pharmacy-costs-in-a-glp-1-world-with-bridget-mulvenna" target="_blank">AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

On this episode of the Astonishing Healthcare podcast, Capital Rx's head of compliance, Heidi McKinnon, PharmD, CHC, joins Justin Venneri for a discussion about a few of the critical issues she's tracking today that are either currently impacting or could impact the pharmacy benefits industry. With over 20 years of experience, she expertly navigates topics like the role of AI in detecting fraud, risks associated with compounding GLP-1 medications, and the nuances of digital pharmacy operations (vs. retail or mail order).

AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC

In this episode of the Astonishing Healthcare podcast, Ben Schuster, Senior Director of Rebate Administration at Capital Rx, joins Justin Venneri for a dive into the world of pharmaceutical rebates. From the basics of what rebates are and how they flow through the supply chain to the intricacies of rebate guarantees and contractual definitions, Ben shares his thoughts on the importance of understanding how various factors can impact the amount of money plan sponsors receive and rebate eligibility (e.g., for GLP-1s).With market dynamics rapidly changing, Episode 22 offers valuable insights into the evolving landscape of drug rebates and highlights the need for transparency and strategic decision-making in navigating the complex pharmaceutical supply chain.Related Content<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-pharmaceutical-rebates" target="_blank">Pharmacy Benefits 101: Pharmaceutical Rebates</a></li><li><a href="https://www.cap-rx.com/insights/will-biosimilar-rebates-pass-through" target="_blank">Will Biosimilar Rebates Pass-Through?</a></li><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-traditional-vs-pass-through-models" target="_blank">Pharmacy Benefits 101: Traditional vs. Pass-Through Models</a></li></ul>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Ben Schuster, Senior Director of Rebate Administration at Capital Rx, joins Justin Venneri for a dive into the world of pharmaceutical rebates. From the basics of what rebates are and how they flow through the supply chain to the intricacies of rebate guarantees and contractual definitions, Ben shares his thoughts on the importance of understanding how various factors can impact the amount of money plan sponsors receive and rebate eligibility (e.g., for GLP-1s).

AH022 - Pharmacy Benefits 101: Pharmaceutical Rebates, with Ben Schuster

In this episode of Astonishing Healthcare, we discuss glucagon-like peptide-1 (GLP-1) agonists, but it's not another "these drugs are going to blow up every plan" sort of discussion. Bridget Mulvenna, a former pharmacy program director and our guest on <a href="https://www.cap-rx.com/insights/ah002---a-former-pharmacy-program-directors-view-on-controlling-pharmacy-costs" target="_blank">Episode AH002</a>, shares her experience and opinions about how plan sponsors can work through the decision-making process to cover GLP-1s for weight loss. She also offers some suggestions for consideration and stresses the importance of leveraging data to understand the needs of each plan's members.Plan sponsors must work closely with pharmacy benefits managers (PBMs) and dive into how coinsurance, prior authorization, third-party point solutions, and other tools or strategies work. The potential impact on the plan's financials and members' experience, as well as the future exposure, must be evaluated today because the GLP-1 drug pipeline is full, and the potential exists for even more new indications on both new and existing GLP-1s.Related Content<a href="https://www.cap-rx.com/insights/how-to-manage-pharmacy-benefit-spend-in-a-glp-1-world" target="_blank">How to Manage Pharmacy Benefit Spend in a GLP-1 World</a><a href="https://www.cap-rx.com/insights/glp-1s-are-no-laughing-matter" target="_blank">GLP-1s are No Laughing Matter</a>Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript!

In this episode of Astonishing Healthcare, we discuss glucagon-like peptide-1 (GLP-1) agonists, but it's not another "these drugs are going to blow up every plan" sort of discussion. Bridget Mulvenna, a former pharmacy program director and our guest on Episode AH002, shares her experience and opinions about how plan sponsors can work through the decision-making process to cover GLP-1s for weight loss. She also offers some suggestions for consideration and stresses the importance of leveraging data to understand the needs of each plan's members.

AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

What do you get when schedules line up and AJ Loiacono and Antonio Ciaccia are the guests on a podcast? An episode you must listen to if your work or interests are in any way centered on drug prices. NADAC - national average drug acquisition cost - was the focus of our discussion on this episode of the Astonishing Healthcare podcast. Recent methodology changes and a new survey participant have combined to drive meaningful deflation in generic drug prices. AJ and Antonio dive into why this is significant and other factors stakeholders should consider.NADAC serves as a crucial price benchmark, providing visibility and some level of understanding - a "source of truth" - of drug pricing in the United States. Average wholesale price (AWP) and other indexes fail to reflect actual acquisition cost/supply chain economics but have prevailed for years. Is it the pharmacy benefits managers (PBMs)? Is it the wholesalers? At Capital Rx, we have always preferred to leverage NADAC whenever possible despite its imperfections. Nothing is perfect in the pharmaceutical supply chain regarding drug pricing, and NADAC remains the best, most reliable option. Tune in to discover what's happened and what to watch for next!Related Content<a href="https://www.cap-rx.com/insights/what-is-nadac-how-does-it-differ-from-awp" target="_blank">What is NADAC &amp; How Does It Differ From AWP?</a><a href="https://www.cap-rx.com/insights/why-use-nadac-based-pricing-over-awp" target="_blank">Why Use NADAC-Based Pricing Over AWP</a><a href="https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html" target="_blank">Medicaid.gov - Drug Pricing</a> (where NADAC lives)Please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a> for more information, including this episode's transcript, AND we'll add links to any new studies or documents that may interest you if you're a student of drug prices or a fan of NADAC.

What do you get when schedules line up and AJ Loiacono and Antonio Ciaccia are the guests on a podcast? An episode you must listen to if your work or interests are in any way centered on drug prices. NADAC - national average drug acquisition cost - was the focus of our discussion on this episode of the Astonishing Healthcare podcast. Recent methodology changes and a new survey participant have combined to drive meaningful deflation in generic drug prices. AJ and Antonio dive into why this is significant and other factors stakeholders should consider.

AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio Ciaccia

On this episode of the Astonishing Healthcare podcast, Casey Stockman, PharmD, Vice President of PBA Services, joins host Justin Venneri and shares her insights on the complexities of high-cost cell and gene therapies (CGTs), glucagon-like peptides (GLP-1s), and much more. Given the advancements in drug development and million-dollar-plus price tags for many of the CGTs, it is crucial for health plans to navigate the challenges of covering these therapies. Casey discusses outcomes-based agreements, annuity or mortgage models for payment plans, and the concept of risk pooling.She addresses concerns surrounding GLP-1s, specifically the expanded FDA approval for reducing major cardiovascular events, affordability and overall uptake of GLP-1s among Medicare patients, and the potential impact of rising utilization on total medical expenses. Casey also emphasizes the benefits of modern technology, such as <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank">JUDI®</a>, in solving real hurdles for health plans by improving the coordination of benefits for dual-eligible members and having the flexibility to meet regulators' intent.Last, Casey shares an astonishing journey from provider to payer to patient.For more information and this episode's transcript, visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>!

On this episode of the Astonishing Healthcare podcast, Casey Stockman, PharmD, Vice President of PBA Services, joins host Justin Venneri and shares her insights on the complexities of high-cost cell and gene therapies (CGTs), glucagon-like peptides (GLP-1s), and much more. Given the advancements in drug development and million-dollar-plus price tags for many of the CGTs, it is crucial for health plans to navigate the challenges of covering these therapies. Casey discusses outcomes-based agreements, annuity or mortgage models for payment plans, and the concept of risk pooling.

AH019 - Wrestling with Coverage of High-Cost CGTs, GLP-1s, and How to Meet Regulators' Intent, with Casey Stockman, PharmD

On this episode of the Astonishing Healthcare podcast, a trio of pharmacists on the Capital Rx team join Justin Venneri and share their experiences and insights related to the residency and fellowship programs (i.e., post-graduate training) that pharmacists often choose to participate in. Allison Gallant, PharmD, Caitlyn Tung, PharmD, MBA, and Nicole Bergman, PharmD, discuss the details of well-designed programs that foster personal and professional growth, the array of traditional and non-traditional settings pharmacists can practice in, what the residency program at Capital Rx - a pharmacy benefit manager (PBM) - looks like, the difference between accredited and non-accredited programs, and much more.Whether you're a pharmacy student, recent graduate, or pharmacy executive interested in how to train the next generation of pharmacists, this episode is for you.For this episode's transcript and much more, please visit <a href="https://www.cap-rx.com/insights" target="_blank">Capital Rx Insights</a>.Thank you for listening!

On this episode of Astonishing Healthcare, a trio of pharmacists on the Capital Rx team join Justin Venneri and share their experiences and opinions about residency and fellowship programs, including the details of well-designed programs that foster personal and professional growth.

AH018 - What's the Right Path? Post-grad Options for Pharmacists

In this episode of the Astonishing Healthcare podcast, we tackle one of the more polarizing issues in healthcare: prior authorization (PA for short). Sara Izadi, PharmD, Capital Rx&#39;s Chief Clinical Officer, Lorece Shaw, PharmD (Director of PA), and Product Manager Callie Burton-Callegari, join host Justin Venneri for a candid discussion about PA. They cover everything from basics like what a PA is, who decides the criteria, and common reasons for denials to why they are necessary and how technology - AI &amp; ML - can help improve PA workflows.Last but not least, the team shares the most astonishing things they&#39;ve seen around PAs, including a personal story!For related content, check out:<ul><li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-what-is-a-formulary" rel="noopener noreferrer" target="_blank">Pharmacy Benefits 101: What is a Formulary?</a></li><li><a href="https://www.cap-rx.com/insights/are-your-prior-authorizations-actually-working" rel="noopener noreferrer" target="_blank">Are Your Prior Authorizations Actually Working?</a></li><li><a href="https://www.cap-rx.com/insights/capital-rxs-judi-r-redefines-the-role-technology-plays-in-the-administration-of-medicare-medicaid-and-commercial-pharmacy-programs" rel="noopener noreferrer" target="_blank">Capital Rx&#39;s JUDI® Redefines the Role Tech Plays in the Administration of Medicare, Medicaid, and Commercial Pharmacy Programs</a> (highlighting our new PAT)</li></ul>For this episode&#39;s transcript and much more, please visit <a href="https://www.cap-rx.com/insights" rel="noopener noreferrer" target="_blank">Capital Rx Insights</a>.Thank you for listening!

In this episode of the Astonishing Healthcare podcast, we tackle one of the more polarizing issues in healthcare: prior authorization (PA for short). Sara Izadi, PharmD, Capital Rx's Chief Clinical Officer, Lorece Shaw, PharmD (Director of PA), and Product Manager Callie Burton-Callegari, join host Justin Venneri for a candid discussion about PA. They cover everything from basics like what a PA is, who decides the criteria, and common reasons for denials to why they are necessary and how technology - AI & ML - can help improve PA workflows.

AH017 - Pharmacy Benefits 101: Prior Authorization

This episode of the Astonishing Healthcare podcast explores the intersection of pharmacy and Medicaid in a relatable and understandable way. Jessin Joseph, PharmD, MBA, Senior Director of Pharmacy Benefits Administration (PBA) Services at Capital Rx, joins Justin Venneri for a discussion that starts with his journey from pharmacy school to Kentucky Medicaid, twists through acronyms like NADAC, AMP Cap, and M3P; and ends with why states are using or interested in preferred drug lists (PDLs) and single PBA solutions.
Jessin highlights the changing rebate landscape for Medicaid (and Medicare) plans, the financial implications of M3P for plans, and the importance of transparency, education, and collaboration in providing care to a vulnerable population.
Please visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for additional content, including this episode's transcript!

This episode of the Astonishing Healthcare podcast explores the intersection of pharmacy and Medicaid in a relatable and understandable way. Jessin Joseph, PharmD, MBA, Senior Director of Pharmacy Benefits Administration (PBA) Services at Capital Rx, joins Justin Venneri for a discussion that starts with his journey from pharmacy school to Kentucky Medicaid, twists through acronyms like NADAC, AMP Cap, and M3P; and ends with why states are using or interested in preferred drug lists (PDLs) and single PBA solutions.

AH016 - The Intersection of Pharmacy, Government Requirements, and Medicaid, with Jessin Joseph, PharmD, MBA

In this episode of the Astonishing Healthcare podcast, Lloyd Fiorini, General Counsel &amp; Chief Compliance Officer at Capital Rx, shares his expertise and experiences from over 25 years in the pharmacy space. He acknowledges that employers and benefits consultants face challenges in a rapidly evolving, complex healthcare landscape. Lloyd covers several topics impacting health plan sponsors and fiduciaries, including the implications of the Consolidated Appropriations Act (CAA) and avoiding penalties and personal liability through effective procurement processes, and the Inflation Reduction Act (IRA) and how disruptive M3P (the Medicare Prescription Payment Plan) implementation could be.&nbsp;
Beyond the CAA and IRA, Lloyd discusses some potential changes in the industry driven by recent lawsuits and legislation; and for all the hockey fans out there, there's a prediction at the end!
Related Content
🏒 <a href="https://www.cap-rx.com/insights/replay-pbm-legislation-navigating-state-and-federal-regulatory-changes-and-how-they-may-impact-you" target="_blank" rel="noopener">Replay: PBM Legislation: Navigating State and Federal Regulatory Changes and How They May Impact You</a>
🏒 <a href="Self-funded%20plans%20ignore%20the%20Consolidated%20Appropriations%20Act%20at%20their%20peril" target="_blank" rel="noopener">Self-funded plans ignore the CAA at their peril</a>
🏒 For more information about M3P and Capital Rx's solution: <a href="https://www.cap-rx.com/solutions/medicare-prescription-payment-plan" target="_blank" rel="noopener">Click Here</a>
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Please visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for additional content, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Lloyd Fiorini, General Counsel & Chief Compliance Officer at Capital Rx, shares his expertise and experiences from over 25 years in the pharmacy space. He acknowledges that employers and benefits consultants face challenges in a rapidly evolving, complex healthcare landscape and covers several topics impacting health plan sponsors and fiduciaries, including the implications of the Consolidated Appropriations Act (CAA) and avoiding penalties and personal liability through effective procurement processes, and the Inflation Reduction Act (IRA) and how disruptive M3P (the Medicare Prescription Payment Plan) implementation could be.

AH015 - PBM Legislation, Contracting, and More, with Lloyd Fiorini

The astonishing potential of artificial intelligence (AI) for personal and professional use, and in healthcare in particular, is what we explore in this episode of <a href="https://www.cap-rx.com/podcast" target="_blank" rel="noopener">Astonishing Healthcare</a> with Christian Ward, Chief Data Officer at Yext, and Carrie Liken, Head of Yext's Healthcare Industry Practice. They discuss the trends they see in search that reflect changing behavior and ultimately influence how people will find information online. Health systems and other healthcare providers must structure their data on the backend and get things lined up properly to ensure accurate search results in a GEO world.
The conversation delves into how to ground AI and prevent the 'hallucination' of information, as well as creative ways to use AI as its capabilities expand to include more senses! Christian and Carrie emphasize the need for organizations to embrace AI and employ a collaborative adoption strategy now rather than taking a wait-and-see approach. They also describe the impact of AI on healthcare journeys and how patients can be directed to the most appropriate resources, thereby reducing waste in the system.
For more information and to get in touch with Christian and Carrie:
<ul>
<li><a href="https://yext.registration.goldcast.io/events/600e97c2-2dee-4631-bd81-1dd261ce395a?utm_source=website-events" target="_blank" rel="noopener">Yext Summit</a> replay(s)</li>
<li><a href="https://www.linkedin.com/in/wardchristianj/" target="_blank" rel="noopener">Christian Ward</a> on LinkedIn</li>
<li><a href="https://www.linkedin.com/in/carrieliken/" target="_blank" rel="noopener">Carrie Liken</a> on LinkedIn</li>
</ul>
Please visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for additional content, including this episode's transcript!

The astonishing potential of artificial intelligence (AI) for personal and professional use, and in healthcare in particular, is what we explore in this episode of Astonishing Healthcare with Christian Ward, Chief Data Officer at Yext, and Carrie Liken, Head of Yext's Healthcare Industry Practice. They discuss the trends they see in search that reflect changing behavior and ultimately influence how people will find information online. Health systems and other healthcare providers must structure their data on the backend and get things lined up properly to ensure accurate search results in a GEO world.

AH014 - The Rise of Conversational AI: Healthcare Search & Patient Journeys Will Never Be the Same

In this episode of the <a href="https://www.cap-rx.com/podcast" target="_blank" rel="noopener">Astonishing Healthcare podcast</a>, Robert Longyear, Co-Founder of Avenue Health, joins Justin Venneri to discuss virtual care and remote patient monitoring, including the role nurses and pharmacists can play as care models evolve and the importance of timely information exchange.
Robert shares his personal journey in healthcare and how his experiences have shaped his mission to improve patient care. He explains Avenue Health's role in launching remote patient monitoring programs for chronic diseases, such as hypertension and diabetes, and the importance of leveraging nurses and other healthcare professionals in providing virtual care. They also discuss challenges in the healthcare staffing space, including clinician burnout and moral injury, and Robert's book, A Virtual Care Blueprint. The conversation concludes with a discussion on the future of virtual care, the power of information exchange, and the need for innovation in the healthcare industry despite the most astonishing thing Robert continues to encounter: resistance to change.
For more information about Robert's book and to get in touch:
<ul>
<li><a href="https://www.routledge.com/A-Virtual-Care-Blueprint-How-Digital-Health-Technologies-Can-Improve-Health-Outcomes-Patient-Experience-and-Cost-Effectiveness/Longyear/p/book/9780367650940">A Virtual Care Blueprint - How Digital Health Technologies Can Improve Health Outcomes, Patient Experience, and Cost</a></li>
<li><a href="https://catalyst.nejm.org/doi/abs/10.1056/CAT.20.0504">Travel ICU Nurse Concerns Across Covid-19 Hot Spots</a> (NEJM)</li>
<li>Robert's <a href="https://www.linkedin.com/in/robert-longyear-a8b284b9/">LinkedIn Profile</a></li>
</ul>
Please visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for additional content!

In this episode of the Astonishing Healthcare podcast, Robert Longyear, Co-Founder of Avenue Health, joins Justin Venneri to discuss virtual care and remote patient monitoring, including the role nurses and pharmacists can play as care models evolve and the importance of timely information exchange.

AH013 - Redefining Virtual Care: A Blueprint for Effective RPM, with Robert Longyear

This episode of the Astonishing Healthcare podcast features the CEOs of Prime Therapeutics, Mostafa Kamal, and Capital Rx, AJ Loiacono. They join Michael Passanante, SVP of Marketing &amp; Communications at Capital Rx, to share the story behind <a href="https://www.cap-rx.com/insights/prime-therapeutics-and-capital-rx-enter-into-transformative-strategic-alliance" target="_blank" rel="noopener">the strategic alliance between the organizations</a> and their vision to reimagine pharmacy and provide better care to patients across the country leveraging next-generation technology: <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank" rel="noopener">JUDI&reg;</a>.&nbsp;
The CEOs emphasize the importance of platform modernization in pharmacy and healthcare more broadly. Prime chose Capital Rx for an alliance and investment due to its complementary capabilities, alignment of core values, and, of course, JUDI, Capital Rx's enterprise health platform. Mostafa and AJ explain the benefits modern health tech can bring to pharmacy plan administration and to plan members, such as rapid deployment of solutions, scalability to navigate the complex regulatory environment, a better overall care experience, and much more.
Visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for this episode's transcript and additional content!

This episode of the Astonishing Healthcare podcast features the CEOs of Prime Therapeutics, Mostafa Kamal, and Capital Rx, AJ Loiacono. They join Michael Passanante, SVP of Marketing & Communications at Capital Rx, to share the story behind the strategic alliance between the organizations and their vision to reimagine pharmacy and provide better care to patients across the country leveraging next-generation technology: JUDI®.

AH012 - Revolutionizing Healthcare: Prime & Capital Rx's Game-Changing Alliance, with Mostafa Kamal & AJ Loiacono

Navigating and understanding government programs in healthcare can be a daunting task. In this podcast episode, Jason Barretto, Vice President of Government Program Operations at Capital Rx, joins Justin Venneri to shed light on the complexities of regulatory compliance and the importance of meeting the intent of legislation and regulations, including the CENTERS for MEDICARE &amp; MEDICAID SERVICES&rsquo; <a href="https://www.cap-rx.com/solutions/medicare-prescription-payment-plan" target="_blank" rel="noopener">Medicare Prescription Payment Plan (M3P)</a> requirements and new Prescription Drug Event (PDE) requirements.
Jason emphasizes the importance of collaboration with health plan partners to ensure alignment and minimize the need for "requesting grace" from governing agencies. Additionally, he explained the significant impact the M3P requirements will have on health plans, pharmacies, and PBMs. He highlights the disruptive nature of this program and introduces Capital Rx's comprehensive end-to-end solution to support health plan pharmacy directors in managing the new requirements. Lastly, he shares a story about an astonishing conference call, which he had to stay on with little to add.
Related Content
<ul>
<li><a href="https://www.cap-rx.com/insights/capital-rxs-government-programs-behind-the-scenes-with-jason-barretto" target="_blank" rel="noopener">Capital Rx&rsquo;s Government Programs: Behind the Scenes with Jason Barretto</a></li>
<li><a href="https://www.cap-rx.com/insights/partnership-collaboration-why-pbms-and-health-plans-should-sync-on-regulatory-change-management" target="_blank" rel="noopener">Partnership &amp; Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management </a></li>
<li><a href="https://www.cap-rx.com/insights/judi-r-is-a-tech-enabler-a-case-study" target="_blank" rel="noopener">JUDI&reg; is a Tech-Enabler &ndash; A Case Study</a>  </li>
</ul>
Visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for this episode's transcript and additional content!

Navigating and understanding government programs in healthcare can be a daunting task. In this podcast episode, Jason Barretto, Vice President of Government Program Operations at Capital Rx, joins Justin Venneri to shed light on the complexities of regulatory compliance and the importance of meeting the intent of legislation and regulations, including the CENTERS for MEDICARE & MEDICAID SERVICES’ Medicare Prescription Payment Plan (M3P) requirements and new Prescription Drug Event (PDE) requirements.

AH011 - Navigating CMS' M3P, PDE, and Other Regulatory Changes, with Jason Barretto

Per member per month (PMPM) cost plays a crucial role in healthcare, particularly in pharmacy benefit management. On this episode of the Astonishing Healthcare Podcast, <a href="https://www.cap-rx.com/team/kristin-begley" target="_blank" rel="noopener">Kristen Begley, PharmD</a>, Chief Commercial Officer at Capital Rx, emphasizes the significance of PMPM guarantees and how they help hold pharmacy benefit managers (PBMs) accountable for total drug spend. The PMPM calculation provides a simplified way to evaluate drug spend by dividing the total plan spend by the number of members. This enables plan sponsors and other industry professionals to&nbsp;easily assess the value and effectiveness of their vendors and predict future costs.
Furthermore, PMPM guarantees prompt PBMs to act in the best interest of both the plan sponsor and the members, ensuring the selection of the most appropriate, cost-effective drugs, for example. Drug mix, formulary decisions, prior authorizations, and clinical programs also strongly influence PMPM and should be carefully considered. Last, Kristin shares the most astonishing thing she's seen, and it's amazing how costly the things people can miss are.
Related PMPM Content
<a href="https://www.cap-rx.com/insights/pmpm-is-it-the-best-way-to-measure-or-track-anything" target="_blank" rel="noopener">PMPM - Is It the Best Way to Measure or Track Anything?</a> 
<a href="https://www.cap-rx.com/insights/pbm-procurement-a-pmpm-guide-for-plans-sponsors-ebook" target="_blank" rel="noopener">PBM Procurement: A PMPM Guide for Plans Sponsors eBook</a> 
&nbsp;
Visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for this episode's transcript and additional content!

Per member, per month (PMPM) cost plays a crucial role in healthcare, particularly in pharmacy benefit management. On this episode of the Astonishing Healthcare Podcast, Kristen Begley, PharmD, Chief Commercial Officer at Capital Rx, emphasizes the significance of PMPM guarantees and how they help hold pharmacy benefit managers (PBMs) accountable for total drug spend. The PMPM calculation provides a simplified way to evaluate drug spend by dividing the total plan spend by the number of members. This enables plan sponsors and other industry professionals to easily assess the value and effectiveness of their vendors.

AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD

Capital Rx Co-Founder and Chief Technology Officer <a href="https://www.cap-rx.com/team/ryan-kelly" target="_blank" rel="noopener">Ryan Kelly</a> joins Justin Venneri for a discussion about the opportunity to bring efficiency to an industry reliant on "horrendously and horribly inefficient" technology and the benefits that modern technology can bring to the administration of a pharmacy benefit program. Some benefits include centralizing all operational workflows and health information in one platform (<a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank" rel="noopener">JUDI&reg;</a>) and data security in the wake of recent cyberattacks.&nbsp;
Ryan also shares his thoughts on AI use cases and how to achieve true value-based care. He explains what frustrates him to no end and the most astonishing thing he [continues to] see in the industry (hint: it should have died long ago, but it's still used and sometimes favored).
Related Content
<a href="https://www.formularywatch.com/view/prime-therapeutics-and-capital-rx-create-technology-alliance" target="_blank" rel="noopener">Prime Therapeutics and Capital Rx Create Technology Alliance</a>
<a href="Capital%20Rx&rsquo;s%20JUDI&reg;%20-%20The%20Beauty%20of%20an%20Open%20Platform" target="_blank" rel="noopener">Capital Rx&rsquo;s JUDI&reg; - The Beauty of an Open Platform</a>
<a href="https://www.cap-rx.com/insights/capital-rx-earns-surescripts-r-certification-soc-2-type-2-report" target="_blank" rel="noopener">Capital Rx Earns Surescripts&reg; Certification &amp; SOC 2 Type 2 Report</a>
&nbsp;
Visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> for this episode's transcript and additional content!

Capital Rx Co-Founder and Chief Technology Officer Ryan Kelly joins Justin Venneri for a discussion about the genesis of JUDI, Capital Rx's enterprise health platform, security in the wake of recent cyber attacks, AI use cases, what frustrates him to no end, and the most astonishing thing he [continues to] see in the industry (hint: it should have died long ago, but it's still used, and sometimes favored).

AH009 - Modern Technology in Healthcare: Enhancing Efficiency & Security, with Ryan Kelly

In this episode of the Astonishing Healthcare podcast, Justin Venneri interviews Josh Golden, who brings his extensive experience as a healthcare consultant and Senior Vice President of Strategy at Capital Rx to the discussion to highlight key questions that plan sponsors should ask to future-proof their pharmacy benefit programs. It is crucial to understand how PBMs make money and how much a plan sponsor is paying their PBM. The answer to the first part helps explain PBMs' behavior, and the answer to the second aids plan sponsors in their decision-making process.
Josh explains the importance of a recent class action lawsuit as it relates to fiduciary responsibility and the pharmacy benefit plan and describes the conflicting fiduciary duties between plan sponsors and traditional PBMs. He also delves into the need for vigilant gatekeeping to control costs and ensure appropriate utilization of expensive medications and why states will continue to lead the way on PBM reform. Josh concludes with a truly astonishing, data-based observation regarding wasteful spending (hint: it can add up quickly)!
Related Content
<ul>
<li><a href="https://www.cap-rx.com/insights/your-pbm-is-the-problem">Your PBM is the Problem</a></li>
<li><a href="https://www.cap-rx.com/insights/auto-refill-or-auto-profit">Auto-Refill, Or Auto-Profit?</a></li>
<li><a href="https://www.cap-rx.com/insights/will-biosimilar-rebates-pass-through">Will Biosimilar Rebates Pass-Through?</a></li>
</ul>
&nbsp;

In this episode of the Astonishing Healthcare podcast, Justin Venneri interviews Josh Golden, who brings his extensive experience as a healthcare consultant and Senior Vice President of Strategy at Capital Rx to the discussion to highlight key questions that plan sponsors should ask to future-proof their pharmacy benefit programs. It is crucial to understand how PBMs make money and how much a plan sponsor is paying their PBM. The answer to the first part helps explain PBMs' behavior, and the answer to the second aids plan sponsors in their decision-making process.

AH008 - Ask the Right Questions to Future-Proof Your Pharmacy Benefit Plan, with Josh Golden

In this episode of the Astonishing Healthcare podcast, Dr. Sunil Budhrani, Chief Innovation and Medical Officer at Capital Rx, discusses the intersection of value-based care and pharmacy. He explains the concept of value-based care in a clear and relatable way and describes how it has evolved over the years. Dr. Budhrani, who remains an active ER physician, shares his experiences from different roles across the healthcare system and highlights the fragmentation and silos that hinder the progress toward a true value-based care system.
He emphasizes the importance of sharing data and integrating pharmacy in value-based care programs to go beyond just scratching the surface, to address the needs of underserved communities and pay physicians for improving patient outcomes and helping to reduce healthcare costs. How do we consider quality, equity, and cost and bring the payer, provider, patient, and pharmacy (the 4 Ps!) together? How important are social determinants of health (SDOH) and aligning incentives? Listen to this episode of the Astonishing Healthcare podcast to find out!&nbsp;
Visit <a href="https://www.cap-rx.com/insights">Capital Rx Insights</a> for this episode's transcript and much more content from the Capital Rx team.

In this episode of the Astonishing Healthcare podcast, Dr. Sunil Budhrani, Chief Innovation and Medical Officer at Capital Rx, discusses the intersection of value-based care and pharmacy. He explains the concept of value-based care in a clear and relatable way and describes how it has evolved over the years. Dr. Budhrani, who remains an active ER physician, shares his experiences from different roles across the healthcare system and highlights how we can move toward a true value-based framework without the fragmentation and silos that hinder progress.

AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD

On this episode of The Astonishing Healthcare Podcast, Amy Stockton, PharmD, who manages the clinical care team at Capital Rx, discusses what, exactly, her team of pharmacists in a non-traditional, managed care setting does (hint: it's a lot behind the scenes). She highlights the clinical programs the team supports, including low-cost alternative, pharmacogenomics, and medication therapy management (MTM), to name a few, what it's like working with frontline customer care, how technology - i.e., <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank" rel="noopener">JUDI&reg;</a> - is leveraged, and the day-to-day responsibilities of a clinical care team member.&nbsp;
Amy also mentions the team's involvement in the Capital Rx residency program and the unique opportunities for growth and specialization in the clinical realm.
For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights">Capital Rx Insights</a>.

On this episode of The Astonishing Healthcare Podcast, Amy Stockton, PharmD, who manages the clinical care team at Capital Rx, discusses what, exactly, her team of pharmacists in a non-traditional, managed care setting does (hint: it's a lot behind the scenes). She highlights the clinical programs the team supports, including low-cost alternative, pharmacogenomics, and medication therapy management (MTM), to name a few, what it's like working with frontline customer care, how technology - i.e., JUDI® - is leveraged, and the day-to-day responsibilities of a clinical care team member.

AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

Discover the ins and outs of Medicare Star Ratings and CMS translation requirements in this insightful podcast episode. Join Capital Rx's Justin Venneri and Jay Tran, PharmD as they delve into the significance of Star Ratings for health plans and Medicare payers, discussing what the ratings are based on, what drives bonus payments, as well as the role of medication therapy management (MTM) in star ratings and upcoming changes in the eligibility criteria. Additionally, this episode explores the importance of the CMS translation requirements for health plans serving diverse populations and provides practical tips for meeting the needs of non-English-speaking members.
For more information on these topics and this episode, please visit <a href="https://www.cap-rx.com/insights" target="_blank" rel="noopener">Capital Rx Insights</a> or check out the linked content below!
<ol>
<li><a href="https://www.cap-rx.com/insights/pharmacy-benefits-101-medicare-star-ratings" target="_blank" rel="noopener">Pharmacy Benefits 101: Medicare Star Ratings</a></li>
<li><a href="https://www.cap-rx.com/insights/what-you-need-to-know-about-2024-cms-translation-requirements" target="_blank" rel="noopener">What You Need to Know About 2024 CMS Translation Requirements</a></li>
</ol>
Thank you for listening!

Discover the ins and outs of Medicare Star Ratings and CMS translation requirements in this insightful podcast episode. Join Justin Venneri and Jay Tran, PharmD as they delve into the significance of Star Ratings for health plans and Medicare payers, discussing what the ratings are based on, what drives bonus payments, as well as the role of medication therapy management (MTM) in star ratings and upcoming changes in the eligibility criteria. Additionally, this episode explores the importance of the CMS translation requirements.

AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD

In this episode of the Astonishing Healthcare Podcast, Jeffrey Hogan, President of Upside Health Advisors, shares his insights on the current state of healthcare and the challenges plan sponsors, including employers and other payers, face. He discusses the importance of aligning supply and demand in the healthcare system in the post-COVID era, the significance of the Consolidated Appropriations Act (CAA), and why establishing a process to evaluate plan data is a must.
Jeff explains short-term steps plan fiduciaries can take to learn about their new responsibilities, gain access to their data, evaluate cost categories like pharmacy (which has been a primary driver of inflation, often compounding at 10%+ per year), and why advanced primary care models are worth a look, too. Finally, Jeff shares the most astonishing thing he's seen over his 35+ years in the business (hint: it's not exactly how you'd want to get out of a tough presentation to a client)!
&nbsp;
Related Content: <a href="https://www.cap-rx.com/insights/self-funded-plans-ignore-the-consolidated-appropriations-act-at-their-peril">Self-funded plans ignore the Consolidated Appropriations Act at their peril</a>
To learn more about Upside Health Advisors, <a href="https://theupsideeffect.com/contact-us">click here,</a>&nbsp;or you can find Jeff on <a href="https://www.linkedin.com/in/jeffhogan06/">LinkedIn</a>.
For more information about Capital Rx and this episode, please visit <a href="https://www.cap-rx.com/insights">Capital Rx Insights</a>.

In this episode of the Astonishing Healthcare Podcast, Jeffrey Hogan, President of Upside Health Advisors, shares his insights on the current state of healthcare and the challenges plan sponsors, including employers and other payers, face. He discusses the importance of aligning supply and demand in the healthcare system in the post-COVID era, the significance of the Consolidated Appropriations Act (CAA), and the importance of establishing a process to evaluate plan data.

AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan

Brian TenEyck, National Director of Consultant Relations at Capital Rx, shares his insights on the pharmacy benefit management (PBM) industry in episode 3 of The Astonishing Healthcare Podcast. He discusses the importance of early engagement in pharmacy procurement and building strong relationships with vendor partners. Brian also addresses the increasing utilization of GLP-1 drugs and suggests consultants inquire about prior authorization (PA) approval rates with their PBMs. He highlights the need to hold PBMs accountable for managing plan spend, urging consultants to monitor the per member per month (PMPM) cost trend for clients rather than solely focusing on discounts and rebates.
Last, he shares one of the most astonishing things he's seen (hint: it led to the creation of a new product for the small and mid-markets).
Visit <a href="https://www.cap-rx.com/insights">www.cap-rx.com/insights</a> for more!

Brian TenEyck, National Director of Consultant Relations at Capital Rx, shares his insights on the pharmacy benefit management (PBM) industry in episode 3 of The Astonishing Healthcare Podcast. He discusses the importance of early engagement in pharmacy procurement, increasing utilization of GLP-1 drugs and prior authorization (PA) approval rates, and the need to hold PBMs accountable for managing plan spend. Brian notes the importance of monitoring per member per month (PMPM) cost trends vs. focusing on discounts and rebates and much more.

AH003 - What's New in the Partner Channel, with Brian TenEyck

Bridget Mulvenna joined Erickson Senior Living to manage pharmacy costs and develop the pharmacy program. She ended up applying what she had learned over years of working in various pharmacy settings and in pharmacy procurement to their pharmacy benefit programs. In this episode of The Astonishing Healthcare Podcast, Bridget shares why it's so hard to control pharmacy costs, as well as her thoughts about reining in specialty drug costs, rebates, coverage of GLP-1s, and the most astonishing thing she's seen (hint: it relates to cost savings)!
For this episode's transcript and to learn more, please visit <a href="Bridget%20Mulvenna%20joined%20Erickson%20Senior%20Living%20to%20manage%20pharmacy%20costs%20and%20develop%20the%20pharmacy%20program.%20She%20ended%20up%20applying%20what%20she%20had%20learned%20over%20years%20of%20working%20in%20various%20pharmacy%20settings%20and%20in%20pharmacy%20procurement%20to%20their%20pharmacy%20benefit%20programs.%20In%20this%20episode%20of%20The%20Astonishing%20Healthcare%20Podcast,%20Bridget%20shares%20why%20it's%20so%20hard%20to%20control%20pharmacy%20costs,%20as%20well%20as%20her%20thoughts%20about%20reining%20in%20specialty%20drug%20costs,%20rebates,%20coverage%20of%20GLP-1s,%20and%20the%20most%20astonishing%20thing%20she's%20seen%20(hint:%20it%20relates%20to%20cost%20savings)!">Capital Rx Insights</a>!

Bridget Mulvenna joined Erickson Senior Living to manage pharmacy costs and develop the pharmacy program. She ended up applying what she had learned over years of working in various pharmacy settings and in pharmacy procurement to their pharmacy benefit programs. In this episode of The Astonishing Healthcare Podcast, Bridget shares why it's so hard to control pharmacy costs, as well as her thoughts about reining in specialty drug costs, rebates, coverage of GLP-1s, and the most astonishing thing she's seen (hint: it relates to cost savings)!

AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs

Capital Rx Co-Founder &amp; CEO AJ Loiacono is our guest for the first-ever episode of The. Astonishing Healthcare Podcast! AJ discusses the path to becoming a pharmacy benefit manager (PBM), why and how using <a href="https://www.cap-rx.com/solutions/pba-judi" target="_blank" rel="noopener">JUDI&reg;</a> aided in the development of a next-generation enterprise health platform, challenges growing through the pandemic and with remote work, what plan sponsors need from their PBM partners, and a most astonishing thing: nobody knows the cost to administer their pharmacy benefit plan!&nbsp;
&nbsp;
Visit <a href="https://www.cap-rx.com/insights">Capital Rx Insights</a> for this episode's transcript and much more content from the Capital Rx team.

Capital Rx Co-Founder & CEO AJ Loiacono discusses the path to becoming a pharmacy benefit manager (PBM). He describes why and how using JUDI® aided in the development of a next-generation enterprise health platform, recounts the challenges of growing through the pandemic and transitioning to a distributed workforce, and shares what plan sponsors need from their PBM partners and what is most astonishing to him  (hint: it relates to knowing the cost to administer a pharmacy benefit plan)!