The discussion covers the growing need to understand what challenges employer plan sponsors face, and why bringing a consultative approach to the table to help solve them is so important. How will moving to a biosimilar-first approach lower net drug costs for plan sponsors? How can a plan cover GLP-1s given their evolution and greater price transparency, expanding clinical indications, and direct-to-plan pricing models? And of course, Bridget shares her views on the sudden acceleration of state and federal PBM reform. As new legislation forces the industry to adapt, plan sponsors must seek forward-thinking platforms already aligned with the changes to provide better pricing and care for members.

Highlights

• Bridget emphasizes the financial advantages of adopting a biosimilar-first approach, which can significantly lower net drug costs for plan sponsors despite smaller rebate checks.
• GLP-1s are transformative medications - price transparency, expanding clinical indications, and direct-to-plan pricing models will influence future plan designs.
• Evaluating PBMs beyond unit costs is critical: formulary management, prior authorizations, and other clinical programs have the greatest impact on total pharmacy spend.
• The rapid acceleration of state and federal PBM reform is astonishing, and alignment with future proof organizations is essential, because there's more to come.

Related Content

• 6 recommendations for PBM procurement and Rx benefits optimization
• AH102 - PBM Reform Update: Health Policy Changes Slowly, Until it Doesn't, with Lloyd Fiorini
• Replay - PMPM vs Clinical Guarantees: A Pharmacist and an Actuary Explain How to Create Predictability Around Pharmacy Spend
• AH064 - Empowering Plan Sponsors: Data Access & Analysis, with Bridget Mulvenna

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Have you ever wondered how AI can streamline notoriously manual clinical workflows? Amit shares his extensive background in AI, from early government projects to leading AI at tech giants, and explains why he joined Judi Health to help fix healthcare. Justin and Amit discuss the top use cases for AI today, including intelligent document processing that tackles the stubborn persistence of fax machines and paper claims, and the evolution of customer service through advanced, human-like AI agents. Finally, Amit offers a compelling glimpse into the future of proactive, personalized healthcare management, aided by AI.

Episode Highlights

• Amit discusses the massive potential AI offers to streamline manual clinical workflows, specifically by automating the ingestion of complex faxed documents, written text, and prior authorization forms.
• Intelligent document processing algorithms can achieve near-perfect accuracy, which reduces the time to response for prior authorizations and lowers operational costs.
• The deployment of customized AI agents in customer service can handle routine member inquiries, deflecting simple calls while assisting human representatives with complex issues.
• The future of healthcare AI lies in proactive, personalized systems that unify pharmacy, medical, dental, and vision data under a single platform.

Related Content

• AH086 - Balancing Technology and a Human Touch in Member Service, with Lisa Ellerhorst and Sonia Pettis
• Health Benefits 101: The Importance of Clinical Programs
• Judi Health wins 7 2026 Stevie® Awards for Sales & Customer Service
• Health Benefits 101: Service Excellence & Scaling an Award-Winning Call Center Model
• Pharmacy Benefits 101: Prior Authorizations

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Lloyd offers clear, helpful explanations of the key takeaways from each of these concurrent reforms aimed at improving transparency and how PBMs operate and interact with the other stakeholders in the supply chain, from independent pharmacies to patients and plan sponsors (employers). Whether you're responsible for a self-funded plan or overseeing a Medicare Part D plan, this episode provides the detail and insights about where the puck is going that you need. As Lloyd said, "I think we've made a great step forward, but the work isn't done."

It's also worth giving a shoutout to previous guest Jim Winkler, as "Change is Imminent" is in the title of AH090!

Episode Highlights

• The Department of Labor’s historic proposed rules on PBM disclosures fills a gap left by the CAA of 2021
• The Consolidated Appropriations Act of 2026 redefines the financial alignment of pharmacy benefits beyond just Medicare Part
• Patient/plan member protection seems to be what the FTC’s recent settlement was all about
• TrumpRx signals a broader shift toward transparent, cost-plus pricing models, but it's just for cash-paying customers, at least for now
• Delinking and efforts to block vertical integration are hotly contested

Related Content

• AH095 - What's in Store for the New Year? A Special Round-Robin Episode of Astonishing Healthcare
• How to obtain Rx data and what to do with it
• AH096 - A Quick Government Programs Update: The IRA & MPPP, Managing D-SNPs, and More, with Jason Barretto
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

Reference Links

• US Department of Labor proposes historic pharmacy benefit manager fee disclosure rule (January 29)
• PBM Reforms Signed Into Law, Reshaping Medicare Part D Drug Pricing Transparency (February 3)
• FTC Secures Landmark Settlement with Express Scripts to Lower Drug Costs for American Patients (February 4)
• TrumpRx Launches (February 6)

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Many administrators rely on antiquated systems that limit customization and data visibility. In contrast, modern platforms empower plan sponsors to integrate point solutions effectively, customize networks for high-value care (e.g., through centers of excellence), and drive better member engagement. If you've ever asked yourself, "What does a TPA really do?" or "Should I look at different TPAs?" this episode will be worth your time to listen to.

Ultimately, successful healthcare administration relies on managing "hundreds of little things" correctly for each benefit (Rx, medical, vision, and dental) - from provider payments to member support. That's how you create positive financial and clinical outcomes.

Related Content

• AH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy Kageleiry
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes
• AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD
• Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards Program

For more information about Judi Health and this episode, please visit Judi Health - Insights.

AJ explains why traditional healthcare giants are facing a "BlackBerry moment" - trying to emulate a conflict-free challenger when "it’s already too late." The balance of power is shifting away from the traditional PBMs, as the industry now demands full transparency - buyers of health benefits today are smarter than ever before. We also discuss how and why the U.S. wastes [at least] a trillion dollars annually by trying to deliver care using inefficient, fragmented systems; we built the infrastructure to stop it. This episode isn't just a retrospective; it’s a blueprint of sorts, and we've got the cultural DNA required to bring about sustainable change (vs. just daydreaming about it).

Related Content

• Replay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and Wellness
• Judi Health’s Capital Rx Surpasses Five Million Contracted PBM Lives as America’s Largest Employers, Unions, and Leading Health Systems Evolve Their Health Benefits Strategies
• AH095 - What's in Store for the New Year? A Special Round-Robin Episode of Astonishing Healthcare
• Health Benefits 101: Service Excellence & Scaling an Award-Winning Call Center Model

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Tune in to hear about:

• Biosimilars - the big opportunity and challenges PBMs have created
• The push for transparency, and what it means for consultants
• How to weigh price/cost, and why drug mix is so important
• Prioritizing member care and programs that benefit members
• The opportunity cost of sticking with the status quo (is astonishing)

Related Content

• How employers can take back control of unnecessary pharmacy spending
• Judi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM Reform
• Replay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary
• Health Benefits 101: Service Excellence & Scaling an Award-Winning Call Center Model

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Highlights

• We've reached a boiling point - everyone is tired of how the US healthcare system operates,, the misaligned incentives throughout the supply chain, and the unnecessary complexity of it all.
• There's a growing willingness among employers to challenge the status quo, embrace transparency, and create customized benefit plans that better serve their unique populations.
• Jeff is driven - in part - by his experience as a public servant, Julie tends to fight for the underdog, and Chris is inspired by the opportunity to make a tangible difference in healthcare.
• The RFP process must be redesigned for each employer, with their unique needs in mind.
• Access to claim-level data is critical if employers are to fulfill their fiduciary duties, make informed decisions, and ensure prudent use of employees' healthcare dollars.

Related Content

• AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?
• Health Benefits 101: The Importance of a Transparent PBM Model
• Replay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and Wellness
• Judi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM Reform

To learn more about the Judi Group, the team, and its mission and services, please visit www.judi.group.

For more information about Judi Health and this episode, please visit Judi Health - Insights.

Disclaimer

This podcast is for informational and entertainment purposes only. The views expressed are those of our guests, do not constitute professional advice, and may not represent Judi Health's/Capital Rx's position on any matters discussed. We make no representations or warranties regarding the accuracy or completeness of the content; information is subject to change and may not be updated.

That said, Episode 97 isn't just about landing an internship or transitioning from an intern to full-time employee. The trio also discusses the engineering, development, and operations/policy work they are doing to help advance our industry. Our goal is really to raise awareness of the different paths the next generation of healthcare disruptors can take, how to prepare if you're on that path, and highlight the reward at the end of this first step in what will undoubtedly be long and successful careers!

To learn more about life at Judi Health, check out our Careers Page, and keep an eye out for our 2026 summer internship program openings, which will be posted there soon.

For more information about Judi Health and this episode, please visit Judi Health - Insights.

During this episode, we discuss:

• Intensifying demand for transparency (beyond just price transparency)
• The Inflation Reduction Act (IRA) and the implementation of Maximum Fair Prices (MFP)
• Slow adoption of the Medicare Prescription Payment Plan (MPPP) and how CMS is removing barriers
• A streamlined approach to managing Dual Special Needs Programs (D-SNPs), something Jason "wanted to solve" when he started here
• A really interesting observation about the popularity of GLP-1s
• CMS changing its audit approach and the importance of audit readiness in 2026

Related Content

• How Our Favorite New Judi® Features Aid Government Programs
• Judi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM Reform
• Judi® is a Tech-Enabler – A Case Study
• AH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya Lomsadze
• Partnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management

For more information about Judi Health and this episode, please visit Judi Health - Insights.

We won’t ruin it in the show notes, but based on what we saw in 2025:

• Everyone has finally had enough of the costs and opacity of the U.S. healthcare system – a $70k family premium is truly astonishing
• It’s surprising that, despite the lawsuits, warnings, and reform efforts, the proverbial hammer didn’t drop on anyone for not being a good health plan fiduciary
• The speed and impact of AI have broadly been more positive than expected
• The rise of cardio-diabesity
• How GLP-1s helped shift the balance of power in the pharmaceutical supply chain

And in 2026, we may see:

• Employers fight back – they take agency over their plans, and for first movers that started with transitioning to aligned PBMs, it’s “game on” for the rest of their health plans
• The cash price – or acquisition cost – of drugs in the U.S. becomes the baseline – i.e., we finally see a real change in how drugs are priced
• ICHRAs and other alternative models become more popular
• Employers look to new clinical programs and models that demonstrate a return on their spending
• AI become more important for clinical workflows (not decision-making, at least not yet)
• Pharmaceutical manufacturers find themselves with increasing bargaining power vs. traditional PBMs
• A new Stanley Cup champion, and a Super Bowl ring for…

Related Content

• Judi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM Reform
• Replay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and Wellness
• AH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency
• Health Benefits 101: The Importance of Clinical Programs
• How to obtain Rx data and what to do with it

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Dr. Bricker shared 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.

Lastly, Dr. Bricker expressed astonishment by the complacency out there, but he was right! The setup was perfect for an acceleration in the pace of change in 2025, and we see the momentum carrying over into 2026 - so, tune in to hear why, if you didn't catch Episode 48 the first time around.

AHealthcareZ Reference Videos

• High Cost Orphan Disease Drugs Explained
• Do Employers Own Their Claims Data? It's Complicated.

Related Content

• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• How to obtain Rx data and what to do with it
• AH093 - Health Benefits that Work for Everyone: Aligning Incentives & Focusing on Members’ Needs, with Susana Villegas Spillman
• Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook (Free)

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Building on Episode 34 - Customer Care in Healthcare: Setting a Higher Bar, and the questions plan sponsors and benefits consultants often ask during the RFP process (Episode 84), this episode covers:

• Several of the most frequent reasons plan members call and how those questions are handled, including switching a prescription from retail to mail and vice versa, prior authorizations for GLP-1s, and more.
• How to navigate transitions and focus on quality care (over speed).
• What it takes to maintain a high level of customer satisfaction (99%) while handling a 50% spike in call volume year-over-year.
• The communication strategy used to educate members and help them navigate new offerings effectively.
• The role of AI and how agentic AI can support member care and free up our skilled, PTCB-certified reps to handle more complex issues.
• Future-proofing the service model and preparing for the 2026 welcome season.

Related Content

• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH017 - Pharmacy Benefits 101: Prior Authorization
• How employers can take back control of unnecessary pharmacy spending
• Capital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer Service
• Watch: Are Your Prior Authorizations Actually Working?

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

The discussion covers the challenges behind supporting complex plan designs, opportunities around automating prior authorizations with real clinical data, and benefits of reducing manual interventions that slow down or interfere with care coordination. Liya and Jake also share stories about launch day, lessons learned from pharmacy claim adjudication, and their vision for a real-time future with integrated benefits. This episode is a must listen for anyone interested in how enterprise health technology can improve health benefit administration and focus resources on what's most important: plan members' experience and improving health outcomes.

Related Content

• Replay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based Care
• AH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy Kageleiry
• Medicare Transition Benefits & How Judi®’s Modern Design Enables Faster Results and Reliable Compliance
• Health Benefits 101: The Importance of Clinical Programs
• This Startup Hit A $3.25 Billion Valuation Building Software To Fix Drug Pricing (Forbes)

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Susana explains how a fragmented system fails members, and while we’ve evolved from the default “call the number on the back of the card” - which directs you to the emergency room - point solutions create more silos, and data is too scattered and stale to drive meaningful change. This forces employers to take control, which leads to her “most astonishing thing,” which is a critical reminder for every benefits leader: “Know what’s in your contracts.”

Episode 93 covers:

• The importance of centering the strategy around long-term goals and member experience (with ruthless accountability).
• The upside of unbundling services from carriers and using independent navigation partners to guide members to high-quality care; why culture fit and flexibility matter when evaluating vendors.
• Why qualitative measures of success offer a better gauge of program effectiveness vs. empty promises of ROI.
• The evolving role of benefits consultants, and how to evaluate consultant relationships.
• The outdated RFP processes and how to run a better RFP.
• GLP-1 coverage for weight loss.

Related Content

• Health Benefits 101: The Importance of a Transparent PBM Model
• Why this benefit leader switched to a more modern, transparent PBM
• Replay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and Wellness
• AH078 - More About Judi Health™ & the Unified Benefits Experience, with Dr. Sunil Budhrani and Mike Tate
• Check out our Health Benefits 101 Content

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Highlights

• Unit-cost-based spreadsheet comparisons and marketing fluff are "out;" evaluating drug mix and how the PBM manages the plan (the 'M' in PBM) or makes money off of the plan are "in."
• Plan sponsors and benefits consultants must demand flexibility - the PBM contract should not be a "house of cards." For example, agreements should provide the freedom to add new vendors or carve out services without collapsing your financial arrangement.
• Legacy tech platforms are a barrier to innovation; ask potential partners if their technology can handle customizations and integrations with agility to avoid being told, "We just can't do that."
• Precise questions about member experience are a must; RFPs should move beyond open-ended questions that invite marketing fluff. Use specific, binary questions to obtain an accurate measure of the member experience and the effectiveness of clinical programs (e.g., NPS, turnaround times for prior authorizations, etc.).

Related Content

• Replay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary 
• Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook 
• AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will Tafoya
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• 5 ways to improve PBM procurement (EBN) 

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Sam describes how we approach understanding each client's unique needs and the importance of consistent messaging across all channels. We dive into ways to keep members informed throughout the year, the benefits of in-person/on-site events, and much more. If you're a "benefits nerd" like us (and Marsha 😀), this episode is for you.

The Articles that Prompted the Episode

• Employers prepare for disruptive and transformative health plan changes, WTW survey finds
• Benefit managers share their 7 open enrollment best practices

Related Content

• AH050 - PBM Pain Points and Overcoming the Fear of Change, with Hope Nakazato, PharmD
• 12 New Judi® Features Innovating Pharmacy Benefit Administration
• AH082 - Pharmacy Benefit Implementations: Have No Fear, Alignment & Process are Here

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Dan paints a picture of a market where employer leverage has returned amidst hiring freezes and layoffs. This newer dynamic intensifies the pressure on benefits teams, who are on the front lines, grappling with the complexities of GLP-1 drug coverage, and the critical need for mental health support, for example. Other highlights of the discussion include:

• AI is widening the skills gap, and many companies are failing to provide adequate training, leaving employees feeling unprepared; this is fundamentally reshaping learning and development needs for 2026.
• The era of the "Great Resignation" is over - employers now have leverage, driving return-to-office mandates and changing the power dynamic.
• Amidst rising costs, a comprehensive and affordable healthcare plan has become a powerful tool for employers - sometimes valued even more than a salary increase.
• Unsustainable healthcare cost increases are reaching a boiling point. Dan predicts 2026 will be the year the system either breaks or fundamentally changes, driven by extreme cost pressures on both employers and employees.
• The gap between what the C-suite thinks about AI and what the workforce says is extraordinarily wide: "We found that 96% of the C-suite expect AI to boost worker productivity... But when we asked employees, 77% of them say that AI has increased their workload. So it's done the exact opposite."

Additional Resources/Links

• Connect with Dan Schawbel on LinkedIn
• Workplace Intelligence Weekly (Free Newsletter - LinkedIn)
• Join Dan Schawbel and Claude Silver, Chief Heart Officer at VaynerX and author of Be Yourself At Work, for an exclusive webinar to look at the Workplace Trends 2026 Forecast: Click Here to Register

Related Content

• AH072 - The Benefits You Probably Didn't Know You Have, with Marsha Perry
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• AH086 - Balancing Technology and a Human Touch in Member Service, with Lisa Ellerhorst and Sonia Pettis
• Health Benefits 101: The Importance of a Transparent PBM Model

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Discussion Highlights

• Costs are expected to rise 9% in 2026, marking the worst multi-year surge in over a decade; it’s another year of healthcare costs rising by more than benefits teams forecasted.
• Pharmacy's share of the total cost has jumped to 24%, driven by expensive GLP-1 and cancer drugs, and some other new cost drivers include mental health and autoimmune conditions.
• Proactive employers have been reviewing their data and are optimizing their programs, cutting underused solutions, investing where there’s a tangible return, and tightening controls on high-cost treatments.
• Employers are aggressively scrutinizing partners and exploring alternative PBM and health plan models, as they should be (vendor accountability has become increasingly important over the years) - change is imminent (i.e., expect an acceleration of RFP activity).

Additional Resources

• 2025 Employer Well-being Strategy Survey: Executive Summary
• Business Group on Health - Resources (Surveys, Data, etc.)

Related Content

• How employers can take back control of unnecessary pharmacy spending
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• Signs it is time to change your PBM vendor, and how to overcome common hesitations
• Health Benefits 101: The Importance of a Transparent PBM Model

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

• How many layers are between your employer's healthcare dollars and care? on LinkedIn (you can see where every $100 an employer spends goes!)
• What would happen if power actually shifted in healthcare? on LinkedIn (5-Way Seesaw)

Andrew discussed how and why:

• A significant portion of the healthcare premium is consumed by administrative layers and middlemen before ever funding patient care.
• Employers can combat wasteful spending by demanding full access to their claims data, then identifying and eliminating things that extract value from their plans (or don't work for their populations).
• Integrated care models (like Kaiser Permanente) and direct primary care help eliminate friction by aligning provider and payer incentives, allowing doctors to focus on practicing medicine (vs. revenue cycle management).
• New technologies like AI-powered prior authorizations may reduce administrative costs for payers but risk creating new burdens for providers and patients, if we're not careful.
• Hospitals face a fundamental conflict: core, life-saving services like ICU and emergency care are often unprofitable and must be cross-subsidized by higher-margin procedures.

Related Content

• How to obtain Rx data and what to do with it
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Pharmacy Benefits 101: Prior Authorizations
• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Lorece, Allison, Hope, and Cindy highlight their career journeys, insights on leadership, and the importance of mentorship to their personal and professional development throughout the discussion. They offer unfiltered advice on career growth, overcoming obstacles, staying resilient and expressing confidence in yourself, and how to work together to fix what's broken in pharmacy and health benefits. Whether you're interested in "non-traditional" career paths for pharmacists, curious about how pharmacists work in managed care, or just need some motivation to go for the next big opportunity and a reminder that you've got to be prepared and show up with confidence, per Allison and Lorece, respectively, this episode is for you!

Related Content

• Signs it is time to change your PBM vendor, and how to overcome common hesitations (by Hope Nakazato, PharmD, MBA)
• AH018 - What's the Right Path? Post-grad Options for Pharmacists
• Pharmacy Benefits 101: Prior Authorizations
• Health Benefits 101: The Importance of Clinical Programs
• AH040 - Celebrating Women Pharmacist Day 2024

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Highlights

• Larger employers may need to tailor flu programs across different states due to varying regulations.
• Federal agencies - ACIP and the CDC - are recommending the annual flu vaccine but are emphasizing single dose formulations that are free of preservatives.
• For people who regularly get or would like to get the flu vaccine, the timing is good now, before the end of October. For other vaccines - COVID, etc. - it's important to discuss timing and need with providers to reach a "shared decision."
• For plan sponsors, working with a PBM partner "to ensure patients have the access that they need and that you're meeting all regulatory compliance" is crucial.
• Judi®'s flexibility helps allow plan sponsors to react quickly and ensure vaccine-related claims are appropriately processed for their populations.

Related Content

• What employers need to know about federal vaccine policy changes (Mercer)
• AH072 - The Benefits You Probably Didn't Know You Have, with Marsha Perry
• AH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock
• 12 New Judi® Features Innovating Pharmacy Benefit Administration

Reference Materials

• Interim Estimates of 2024–2025 Seasonal Influenza Vaccine Effectiveness — Four Vaccine Effectiveness Networks, United States, October 2024–February 2025
• RSV monoclonal antibody nirsevimab 83% effective in babies, data reveal
• BEYFORTUS® reduced hospital and doctor visits for RSV disease in babies by 87%, according to largest US real-world study

For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

• Several of the most frequent reasons plan members call and how those questions are handled, including switching a prescription from retail to mail and vice versa, prior authorizations for GLP-1s, and more.
• How to navigate transitions and focus on quality care (over speed).
• What it takes to maintain a high level of customer satisfaction (99%) while handling a 50% spike in call volume year-over-year.
• The communication strategy used to educate members and help them navigate new offerings effectively.
• The role of AI and how agentic AI can support member care and free up our skilled, PTCB-certified reps to handle more complex issues.
• Future-proofing the service model and preparing for the 2026 welcome season.

Related Content

• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• Watch: Are Your Prior Authorizations Actually Working?
• AH017 - Pharmacy Benefits 101: Prior Authorization
• How employers can take back control of unnecessary pharmacy spending
• Capital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer Service

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Additional highlights from the conversation with Andy include:

• How modern technology - Judi® - helps make life easier by giving the Valeris team control and the flexibility to quickly design programs, test new features, and monitor their programs through detailed reporting.
• How copay cards help with brand-name prescription drugs, especially those with higher price tags or drugs that are on the higher tiers of insurance (where out-of-pocket costs can be significant): "They're super common in competitive drug categories like diabetes, or asthma, or psoriasis, where multiple branded drugs are fighting for market share."
• What the patient pays: these programs differ in terms of cost for patients, but all are designed to improve access. Some programs have a maximum dollar amount or a limit on the number of fills you can get; others are more flexible and don't have a cap at all.
• An astonishing - but all too common - example of a patient who was able to overcome embarrassment and access an expensive branded injectable at no cost.

Related Content

• 12 New Judi® Features Innovating Pharmacy Benefit Administration
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes
• AH081 - Promoting Competition & Innovation: The Push for PBM Reform, with Rep. Jake Auchincloss
• Health Benefits 101: The Importance of a Transparent PBM Model
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Highlights

• Unit-cost-based spreadsheet comparisons and marketing fluff are "out;" evaluating drug mix and how the PBM manages the plan (the 'M' in PBM) or makes money off of the plan are "in."
• Plan sponsors and benefits consultants must demand flexibility - the PBM contract should not be a "house of cards." For example, agreements should provide the freedom to add new vendors or carve out services without collapsing your financial arrangement.
• Legacy tech platforms are a barrier to innovation; ask potential partners if their technology can handle customizations and integrations with agility to avoid being told, "We just can't do that."
• Precise questions about member experience are a must; RFPs should move beyond open-ended questions that invite marketing fluff. Use specific, binary questions to obtain an accurate measure of the member experience and the effectiveness of clinical programs (e.g., NPS, turnaround times for prior authorizations, etc.).

Related Content

• Replay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary 
• Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook 
• AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will Tafoya
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• 5 ways to improve PBM procurement (EBN) 

For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Highlights

• Traditional PBMs remain focused on rebate value, which doesn’t always mean the lowest net cost for the plan sponsor.
• Biosimilar adoption and precision formularies/benefits are a threat to old models.
• Plan sponsors must get [and use] their data - without detailed information, it's impossible to determine the true net cost or implement effective communication and education strategies.
• GLP-1s should be supported by wellness programs, and respecting FDA labeling is crucial.
• Surprisingly, many plan sponsors still choose the PBM that offers the highest rebates.

Related Content

• Will Biosimilar Rebates Pass-Through?
• Health Benefits 101: The Importance of a Transparent PBM Model
• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• Pharmacy Benefits 101: What is a Formulary?
• Pharmacy Benefits 101: Pharmaceutical Rebates

For more on the importance of access to plan data:

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

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

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Tracey and Kristen explain how employers and health plans can prepare for and manage the transition to a new pharmacy benefits partner, emphasizing the role that the PBM should play and the importance of making strategic decisions early in the process to build trust and ensure a seamless implementation. They highlight how the process improves with time and growth, offering more reassurance that clients' needs can be met, recent trends and enhancements to the process (e.g., that larger employers are starting the process earlier than ever and becoming more sophisticated), and the role advanced technology platforms like Judi play in maintaining flexibility and compliance in a rapidly evolving regulatory landscape.

Related Content

• Pharmacy Benefits 101: Successful Implementations
• Signs it is time to change your PBM vendor, and how to overcome common hesitations
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes
• Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Auchincloss stresses the importance of challenging entrenched corporate practices to create a healthcare system that prioritizes price transparency, patients, and encourages technological innovation - such as new drug development or medical devices - in key areas affecting millions of Americans. For example, why not make curing Alzheimer's, which is expected to impact upward of 60 million people by 2025, our 'moonshot'?

Highlights

• Mandatory NADAC reporting (cost-plus, with a fair dispensing fee) and banning spread pricing, steering, and other traditional PBM business practices will help stabilize retail pharmacies and protect payers and patients from misaligned incentives.
• The federal government should promote competition in areas where there's an obvious and immediate positive impact, such as the development of generic and biosimilar drugs.
• Improving technology for "hospital at home" and long-term care for the elderly should be a focus.
• Price controls won't work for drugs, and there's more work to do on price transparency for medical care.
• Value-based contracts make sense - GLP-1s are a good example/potential application. We should be paying for performance.
• Congress should promote community health centers more because "they are really meeting people where they're at with the services that they need."

Related Content

• The Role of Pharmacy Benefit Managers in Prescription Drug Markets Part III: Transparency and Accountability (Rep. Auchincloss at 4:31:00)
• AH052 - ERISA Insights: Challenges & Compliance in Modern Healthcare, with Nick Welle
• RELEASE: AUCHINCLOSS INTRODUCES BIPARTISAN PHARMACISTS FIGHT BACK ACT TO CRACK DOWN ON PREDATORY DRUG PRICING
• What is NADAC & How Does It Differ From AWP?

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Andy provides an overview of the basics, highlighting the spectrum of care navigation solutions and how smart technology can enhance them. He then dives into how AI can transform care delivery by removing barriers before patients encounter them and delivering more personalized experiences.

Key Discussion Highlights

• True integration isn’t just about convenience; it’s about creating a seamless experience that anticipates and eliminates roadblocks before they occur.
• Having a unified front door to care, encompassing medical and pharmacy benefits, and unified claim processing on the backend, enables the delivery of new solutions that improve the member experience and help drive utilization of the benefits that plan sponsors carefully choose for their members.
• Leveraging data and AI, we can provide relevant information in conversational ways to help plan members find the care they need, when they need it.

Related Content

• Capital Rx Acquires Care Navigation Company Amino Health
• Health Benefits 101: The Importance of a Transparent PBM Model
• AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch

Reference Articles

• Same Surgery, $220K Apart: Why Providers & Employers Need to Rethink Value Amid Price Disparities (MedCity News; 8/18)
• Business Group on Health. 2026 Employer Health Care Strategy Survey (August 2025)

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Related Content

• AH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock
• Pharmacy Benefits 101: Pharmaceutical Rebates
• AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD
• How to Manage Pharmacy Benefit Spend in a GLP-1 World

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Additionally, the conversation with Sunil and Mike covers:

• The importance of empowering patient-provider relationships
• The need for greater transparency and access to data to see what's driving costs
• How a platform that allows for flexibility and personalization helps lower costs and provides for a better member experience

Related Content

• Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards Program
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• Health Benefits 101: The Importance of a Transparent PBM Model
• Replay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based Care

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Highlights

• Deprescribing Defined: The process of discontinuing potentially inappropriate medications under a healthcare provider's supervision.
• Judi® identifies drug therapy concerns in real-time, even across multiple prescribers and pharmacies.
• Rx Retro's Two Levels: Level 1 involves fax notifications to prescribers, while Level 2 includes direct pharmacist outreach and patient counseling.
• Broader Impact: Rx Retro addresses clinical areas like polypharmacy, duplication of therapy, and high-risk medications in vulnerable populations, and can help with quality metrics and scores that impact plans' star ratings.

Related Content:

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Pharmacy Benefits 101: What’s the Drug Management Program (DMP)?
• AH073 - How Low Cost Alternative Programs Can & Should Work, with Jackie Lolos, PharmD, and Haleh Campbell, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Highlighting the evolving role of PBMs and Capital Rx's expansion into medical benefit administration, it's apparent that the opportunity to reduce waste and take back control of benefits programs exists; however, "medical is worse," Hogan says. So, what is a plan sponsor or benefits consultant to do? Dig into those contracts - all of them (administrative services, broker, and stop-loss, to name a few) - and look at the provisions you're paying for! "This is where you discover the schemes that are occurring," he adds.

Lastly, Jeff notes an interesting trend with health systems and direct contracting that's worth a listen, especially if you liked AH075 - What Health Systems Need [From a PBM]: A Blend of Tech, Transparency, and Understanding, with Lindsey Butler, PharmD, and Chris England.

Related Content

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Signs it is time to change your PBM vendor, and how to overcome common hesitations (BenefitsPRO)
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact

To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Highlights

• Arkansas and Louisiana are among the states leading PBM reform efforts, and fiduciary responsibility is in focus - Lindsey discusses ERISA lawsuits and the Arkansas bill, while Chris talks about the push to use NADAC for drug pricing.
• Health systems are grappling with the high costs of GLP-1 drugs and exploring ways to integrate wraparound support, such as nutrition counseling, to improve outcomes - it's interesting that most health systems do cover them for weight loss!
• Many health systems are leveraging - or considering opening - in-house pharmacies to reduce costs, improve medication access, and enhance continuity of care.
• Having a PBM partner with flexible technology allows for custom network and reimbursement structures that align pharmacy benefits with health systems' goals.
• Collaboration among providers, pharmacies, and health plans is essential to ensure that decisions benefit both a health system and the patients it serves.

Related Content

• Pharmacy Benefit Procurement: How to Ensure That Savings Materialize (eBook)
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna & How to Manage Pharmacy Benefit Spend in a GLP-1 World (Blog)
• AH029 - Selling Pharmacy Benefits: Building Relationships & Meeting Clients' Needs, with Nick Van Hook
• Pharmacy Benefits 101: The Importance of the Network

To get in touch with Lindsey: Lindsey Butler, PharmD, CSP

Please visit Capital Rx Insights for more information, including this episode's transcript!

Highlights include:

The Decline of Traditional Websites: AI Mode summarizes information directly on search results, reducing the need for users to visit websites and challenging healthcare organizations to rethink their content strategies.

The Importance of Data Strategy: Carrie emphasizes that a robust data strategy is essential for organizations to succeed in an AI-driven world.

The Role of AI in Patient Journeys: AI tools can guide patients through initial research and even help locate care providers, though booking appointments still requires human interaction.

The Future of AI Agents in Healthcare: Carrie envisions AI agents automating tasks such as appointment scheduling and care coordination to significantly reduce friction in the healthcare system.

Related Content & Reference Materials

• Maybe we should write an obituary for the website (3/20/25)
• AI Mode is the training ground for AI Overviews (and yes, websites are still dying) (6/7/25)
• AH070 - Inside Capital Rx's Acquisition of Amino Health: Creating the Health Benefits Platform of the Future, Today

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Jackie and Halls outline how the two levels of Rx Smart Save work, with Level 1 empowering members to independently switch to lower-cost, clinically equivalent medications via notifications on the Capital Rx app or web portal. Level 2 increases access with a proactive, high-touch approach, where a team of pharmacists and specialists assist members, prescribers, and pharmacies throughout the process. Halls also shares a quick case study demonstrating how one retiree saved $75 per prescription by switching from an injection-based migraine treatment to a tablet, and Jackie explains how modern technology aids the process..

Related Content

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Signs it is time to change your PBM vendor, and how to overcome common hesitations (Capital Rx / Benefits Pro)

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Additionally, Marsha offers some specific examples of "benefits people [often] forget they have," and she dives into the importance of dental benefits (a surprisingly underutilized benefit). Lastly, but not least, Marsha shares her opinions on covering GLP-1s and the importance of maintaining a solid relationship with the finance team.

Related Content

• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes

Please visit Capital Rx Insights for more information, including this episode's transcript!

Additional Reference Materials (IQVIA Institute Reports & Publications)

• Assessing the Biosimilar Void in the U.S.
• Proliferation of Innovation Over Time

Related Content

• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker
• AH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAA
• Replay - Innovative partnerships for GLP-1 management, with Vida Health
• How to Manage Pharmacy Benefit Spend in a GLP-1 World

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Liya and host Justi Venneri dive into several recent updates to the Judi® platform, highlighting Judi's overall agility and how it aids in the administration of benefit plans for Capital Rx's clients. During the discussion, they also explore:

• Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.
• Judi's ability to ingest historical claims data for seamless onboarding of new clients.
• The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).
• Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.
• Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.
• How Judi Health aims to streamline member care and improve the patient experience.

Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.

Related Content

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®
• How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration
• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

We're incredibly excited about the future and the opportunity to meaningfully improve access to care and the overall health benefits experience while helping reduce costs. Capital Rx has evolved into an HBM - or health benefits manager - as a result of Judi® processing medical AND pharmacy claims (and supporting all related workflows in one system), and a unified front end that "puts quality, cost insights, and all of the benefits that your health insurance provides into one simple search box" is a natural extension of our enterprise health tech capabilities. We hope you enjoy learning more about our journey and evolving mission!

Related Content

• Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards Program
• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Capital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025
• AH065 - The Bridge to Value-Based Care: Unified Claims Processing™, with Dr. Sunil Budhrani

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

We won't give away the conclusions, but Zach explains the team's research on International Classification of Diseases (ICD) codes and how they evaluated the accuracy and reliability of ICD codes submitted on pharmacy claims. Additionally, they sought to identify patterns in ICD code submissions across client types, drug classes, disease states, pharmacy networks, and regions.

Nash highlights how text messaging and pharmacist outreach to patients through Rx Enhance - a clinical program designed to improve adherence and close gaps in care - drove marked improvement in medication adherence in 2024 for commercial plan members with diabetes, hypertension, and high cholesterol. If you're interested in the potential to streamline processes and improve decision-making by using data like ICD codes, or the potential for tech-enabled clinical programs to improve health outcomes, this episode is for you!

Reference Materials & Related Content

• Poster: Evaluating ICD Codes on Pharmacy Claim Submissions: Are They Reliable?
• Poster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM Population
• AH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmD
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

Please visit Capital Rx Insights for more information, including this episode's transcript!

Burns and Caitlin discuss the growth of biomarkers on drug labels and use cases where PGx has been most helpful to date (e.g., behavioral health), the cost of testing, lack of insurance coverage and appropriate clinical guidelines, and the general level of physician awareness. They also dive into ongoing efforts to overcome the common barriers to using PGx and how Capital Rx is approaching the opportunity - leveraging Judi® - to bring PGx to employer plan sponsors and others who would like to offer plan members this option as part of the health benefits program. They also highlight the important role pharmacists can play on care teams and in the delivery of specialized care and acknowledge that regulation and legal action will help drive change and improve greater accessibility and usage of PGx tools, which, based on some of the stories shared, can transform the patient experiences and improve health outcomes.

Related Content & Reference Materials

• Validation of Pharmacogenomic Interaction Probability (PIP) Scores in Predicting Drug–Gene, Drug–Drug–Gene, and Drug–Gene–Gene Interaction Risks in a Large Patient Population
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Related Content

• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• Pharmacy Benefits 101: The Importance of the Network
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• Signs it is time to change your PBM vendor, and how to overcome common hesitations
• AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Why did Mike join Capital Rx? How is a rising "Healthcare IQ" impacting the market? What are plan sponsors thinking about strategically? Listen in to find out!

Related Content

• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform
• Why this benefit leader switched to a more modern, transparent PBM
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Today, Sunil discusses our experience thus far - 5 months into our unified claims experience - and the importance of flexibility in plan design to achieve a plan's goals. He also explains how Judi Health helps to empower providers and the provider-patient relationship via a "transparent architecture." What should the experience be like for patients? How about the plan sponsor/HR team side of the equation? Tune in to find out and hear why Judi Health represents an "opportunity to see - and achieve - what many people in healthcare say cannot exist" (hint: it's a win for all stakeholders).

Related Content:

• Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards Program
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform
• AH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya Lomsadze
• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• Setting a New Standard for the Future of Pharmacy Benefit Administration

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

What data do you need? Who can/should do the analysis? What do contract definitions have to do with this? We cover it all, offering practical suggestions to hold partners accountable based on Bridget's experience.

Related Content

• Why this benefit leader switched to a more modern, transparent PBM.
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker
• AH053 - Selling Pharmacy Benefits: Relationships, Rebates, GLP-1s, and More, with Bridget Mulvenna

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In Episode 16 - The Intersection of Pharmacy, Government Requirements, and Medicaid, Jessin highlighted the momentum that discussions around single PBM seemed to have, and this time around, nearly a year later, he dives into why everyone is talking about unbundling the pharmacy benefit!

Related Content

• Replay: How You Can Leverage Modern Technology to Meet the CMS Medicare Prescription Payment Plan Requirements
• Partnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management 
• AH033 - Never Move Again™, a Paradigm Shift in Pharmacy Benefits, with AJ Loiacono (for more on unbundling)

Please visit Capital Rx Insights for additional content, including this episode's transcript!

AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively.

Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health’s innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies.

The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.

Related Content:

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Capital Rx 2025 Partner Summit Highlights: The Future of Claim Administration & Benefit Management
• Setting a New Standard for the Future of Pharmacy Benefit Administration
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

Please visit Capital Rx Insights for more information, including this episode's transcript!

As a requirement of the Consolidated Appropriations Act of 2021, RxDC demands detailed annual data submissions by plan issuers, TPAs, and others. Spencer explains the importance of starting early, understanding the data submission components, tackling coordination complexities, and ensuring accuracy. You'll want to be working with a partner here, not "just a vendor." Spencer emphasizes the importance of cooperation and maintaining detailed records to avoid friction and streamline the reporting process.

Related Content

• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker

Visit CMS.gov for RxDC-Related Resources

• https://www.cms.gov/marketplace/about/oversight/other-insurance-protections/prescription-drug-data-collection-rxdc

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• 12 New Judi® Features Innovating Pharmacy Benefit Administration
• AH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAA
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform

Please visit Capital Rx Insights for more information, including this episode's transcript, or to get in touch!

Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses the urgent need for increased screening awareness and greater access to screening tools, noting that employers can help overcome barriers to screening through education and by encouraging engagement in wellness programs. Other topics covered include:

• Over 135,000 people are diagnosed with CRC every year, and despite CRC being one of the most preventable cancers with good long-term survival rates following treatment, 50,000 people die from it annually.
• Preventive screenings are increasingly covered with no patient out-of-pocket costs, but insurers' expenses are rising.
• Increasing early screening is crucial: 30-40% of eligible individuals remain unscreened, particularly in the 45-49 age group.
• Geneoscopy's decentralized clinical trial and overall use of technology to conduct its pivotal FDA approval study virtually, which increased patient diversity and efficiency.
• Regulatory challenges remain: FDA approval is just one step; Medicare coverage and guideline inclusion are key hurdles.
• Bringing targeted therapy approaches to autoimmune diseases like IBD to improve patient outcomes and reduce costs is Geneoscopy's next goal.

Related Content

• Multitarget Stool RNA Test for Colorectal Cancer Screening. Barnell EK, Wurtzler EM, La Rocca J, et al. JAMA. 2023;330(18):1760–1768. doi:10.1001/jama.2023.22231
• Pharmacogenomics (PGx) 101: What You Need to Know for Rx Programs

Reference Materials/Other Links (courtesy of Geneoscopy)

• Projected Impact and Cost-Effectiveness of Novel Molecular Blood-Based or Stool-Based Screening Tests for Colorectal Cancer. Ladabaum U, Mannalithara A, Schoen RE, Dominitz JA, Lieberman D. Ann Intern Med. 2024 Dec;177(12):1610-1620. doi: 10.7326/ANNALS-24-00910. Epub 2024 Oct 29. PMID: 39467291.
• Colorectal Cancer—Patient Version. National Cancer Institute (NCI)
• Productivity savings from colorectal cancer prevention and control strategies. Bradley CJ, Lansdorp-Vogelaar I, Yabroff KR, Dahman B, Mariotto A, Feuer EJ, Brown ML. Am J Prev Med. 2011 Aug;41(2):e5-e14. doi: 10.1016/j.amepre.2011.04.008. PMID: 21767717; PMCID: PMC3139918.
• Follow Geneoscopy on LinkedIn

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

The discussion also covers areas of focus for 2025, including:

• Palmer's favorite Vanguards of Healthcare podcast episodes and why he enjoys speaking with private company CEOs and venture capital leaders
• Biopharma Innovation, including GLP-1s, oncology readouts
• MedTech Advancements like surgical robotics, cardioablation, and evolving insulin delivery systems
• Capital Spending Concerns as US providers and China's healthcare sector are under scrutiny
• Healthcare Services: online pharmacy growth and Medicare Advantage trends

Reference Materials Courtesy of Bloomberg Intelligence

• North America Managed-Care Policy Outlook
• N.A. Health-Care Tech, Distribution: 2025 Outlook

Related Content

• Vanguards of Health Care: How Capital Rx is Fixing America's Broken Drug Pricing
• AH057 - How First-Movers are Taking Control of their Health Plans in 2025, with Jeff Hogan
• AH047 - What Project 2025, RFK Jr., and Dr. Oz Could Mean for the Business of Healthcare Under Trump
• AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

• Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.
• Judi's ability to ingest historical claims data for seamless onboarding of new clients.
• The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).
• Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.
• Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.
• How Judi Health aims to streamline member care and improve the patient experience.

Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.

Related Content

• Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®
• Pharmacy Benefits 101: Prior Authorizations
• How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration
• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

The discussion also covers the increasing use of analytics - including platforms like HOMA Health - or outside resources, like Nick Welle explained on Episode 52, to help plan employer plan sponsors manage costs and their vendor contracts, PBM reform, and point solution fatigue. Finally, Jeff outlines key priorities for 2025, including fiduciary compliance, confirming the removal of gag clauses from contracts, and greater transparency in broker compensation to ensure better alignment between healthcare purchasers and providers.

Related Content

• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• Best of '24! AH041 - ERISA Litigation Outlook and Meeting CAA Requirements, What Can Plan Fiduciaries Do?
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.

Resources Mentioned

• Vizient - 2025 Trends Report: Strategy is (finally) back in the driver’s seat
• Peterson Health Tech Institute - Virtual Musculoskeletal Solutions (June 2024)
• ICER - Peterson Health Tech Institute: Assessment Framework for Digital Health Technologies (Sept. 2023)
• Peterson Health Tech Institute - Digital Diabetes Management Solutions (March 2024)

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

The conversation highlights the positive impact early interventions can have and how innovative enterprise health technology like Judi® allows for real-time insights. As CMS proposes changes, such as possibly removing the MTM - medication therapy management - measure or others like limiting initial opioid supply, having the flexibility to react quickly helps immensely. Angela also provides some strategic insights into how to navigate the evolving landscape and achieve superior ratings.

Related Content

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Mike comments on broader cost drivers, using GLP-1s as an example, preliminary book-of-business trends (2024 vs. 2023), the importance of surveillance on emerging claims, and more!

Related News & Content:

• Sun Life sees stop-loss problems spiking: Will it force employers to buy fully insured coverage? (BenefitsPro)
• AH031 - Dissecting Pharmacy Cost Drivers and the Value of PMPM, with Kristin Begley, PharmD, and Mike Miele, FSA, MAAA
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform

Please visit Capital Rx Insights for more information, including this episode's transcript!

Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health’s innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies.

AJ Loiacono reflects on the journey of building Judi Health and the importance of firsthand experience in workflow optimization. Dr. Budhrani stresses the importance of transparency and collaboration among the stakeholders, underlining how Judi Health can break down silos to improve care delivery and outcomes. They offer practical examples of how Judi Health can work, such as diabetic-specific plan designs and improved workflows for cancer care.

The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.

Related Content:

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Setting a New Standard for the Future of Pharmacy Benefit Administration
• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

Please visit Capital Rx Insights for more information, including this episode's transcript!

Previous AH episodes featuring Bridget:

• AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

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 Never Move Again™ offering, Bridget emphasizes its flexibility and appeal to sophisticated plan sponsors.

Related Content:

• Pharmacy Benefits 101: Pharmaceutical Rebates
• Our Single-Ledger Model™ - Pharma Revenue Explained
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan

Please visit Capital Rx Insights for more information, including this episode's transcript!

They dive into common traps Nick has seen employers fall into, processes and resources to leverage to show that "homework" - i.e., reasonable due diligence - is being done on the vendors providing services to the plan and its members, and much more. The ability to see and evaluate plan data and costs has never been more important!

Note that Nick's comments on this podcast are his own personal comments and do not represent any views or positions of the clients of Foley & Lardner.

Reference Materials for Plan Sponsors

• Employer Checklist for New Health Plan Price Transparency Rules and CAA
• Final Mental Health Parity Rules – Top Five Changes to the Status Quo

Related Content

• AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?
• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• The Consolidated Appropriations Act (CAA): Kudos to the Department of Labor (AJ Loiacono at ViVE)

To connect with Nick, CLICK HERE.

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• What is NADAC & How Does It Differ From AWP?
• Pharmacy Benefits 101: The Importance of the Network

For Reference

• Hospice industry Facts & Figures (NHPCO, 2024)

Thank you for listening, and check out Capital Rx Insights for more, including this episode's transcript!

Hope uses the book, "Who Moved My Cheese?", by Dr. Spencer Johnson, to explain the fear of change, as well as three things people can look for in a true partner who will work with them in a collaborative and generally supportive way. If a new PBM or other vendor is aligned, consistent, and future-proof, change won't be as scary as it may seem, and plan sponsors can make more strategic decisions benefiting the plan and its members.

Hope also shares the advice she'd give her younger self, as well as the most astonishing thing she's seen over the years (hint: it relates to drug prices).

Related Content

• Capital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025
• Pharmacy Benefit Procurement: How to Ensure That Savings Materialize
• Replay: 5 Ways to Improve Your PBM Procurement Process In 2024 (stay tuned for the 2025 edition!)
• 5 Recommendations for an Optimal PBM Deal (free eBook)

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC
• AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD

Reference Materials

• The Capital Rx Pharmacy Provider Manual
• PHARMACY AUDITS, An Important Tool for Fighting Fraud, Waste, and Abuse and Protecting Patients
• PAAS National - Home Page

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• High Cost Orphan Disease Drugs Explained
• Do Employers Own Their Claims Data? It's Complicated.

Related Content

• Replay - Cracking the Code: Unraveling Specialty Drug Costs & PBM Profits
• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan

Please visit Capital Rx Insights for more information, including this episode's transcript!

In Episode 41, we discussed what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.

This episode built on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.

Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"

Related Content

• AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• Self-funded plans ignore the Consolidated Appropriations Act at their peril

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

NADAC serves as a crucial price benchmark for our industry, providing freely available visibility and some level of understanding - a "source of truth" - of drug prices in the United States. Average wholesale price (AWP) and other indexes fail to reflect actual acquisition cost/supply chain economics but have prevailed for years. Is it the pharmacy benefits managers (PBMs)? Is it the wholesalers? At Capital Rx, we have always preferred to leverage NADAC whenever possible because of its numerous positive attributes. Tune in to learn more about the changes that occurred early in 2024, and you can click here to see the most recent updates to NADAC.

Related Content

What is NADAC & How Does It Differ From AWP?

Why Use NADAC-Based Pricing Over AWP

Medicaid.gov - Drug Pricing (where NADAC lives)

Please visit Capital Rx Insights for more information, including this episode's transcript, AND we'll add links to any new studies or documents that may interest you if you're a student of drug prices or a fan of NADAC.

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

• Analyzing Health Policy Priorities under RFK, Jr. and Dr. Oz (Nov 27)
• What to Expect in Health Policy from the Next Trump Administration (Project 2025 Analysis; Nov 7)
• Digital Health Technologies in Rural Health: Bridging the Gap in Care Access and Delivery (Nov 26)
• AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan

Visit Health Tech Happy Hour for more of Robert's work.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna
• What is NADAC & How Does It Differ From AWP?
• AH022 - Pharmacy Benefits 101: Pharmaceutical Rebates, with Ben Schuster

To connect with Tom or for more information about RSM's Life Sciences Group/Management Consulting Services, please visit:

• Connect with Tom Evegan (LinkedIn)
• Life Sciences | Industries | RSM US
• Scaling at the Speed of Change: Biopharma

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

• New York City FC and Capital Rx Announce Sleeve Partnership
• Prime Therapeutics and Capital Rx Enter Into Transformative Strategic Alliance
• Capital Rx's Customer Care Team Wins 5 Stevie® Awards for Customer Service
• 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
• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™

Fortunately, the overarching message/theme remains highly relevant, and AJ's experience and insights are always interesting to hear. Employer plan fiduciaries and health plans need aligned, focused, and unconflicted partners with next-generation technology to support their benefit programs (and operations) in a rapidly evolving environment. This goes well beyond just being transparent or passing through pharma revenue on the PBM side, which are bare minimum expectations at this point.

All that said, Happy Thanksgiving, and if you like what you're hearing, please share the podcast with your network!

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Pharmacy Benefits 101: What is a Formulary?
• Replay - Cracking the Code: Unraveling Specialty Drug Costs & PBM Profits
• Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

*If you'd like to dive into the details of a formulary, check out Capital Rx's Freedom (Open) Formulary Lookup or Capital Rx’s Liberty (Closed) Formulary.

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

• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• Pharmacy Benefit Procurement: How to Ensure That Savings Materialize
• AH014 - The Rise of Conversational AI: Healthcare Search & Patient Journeys Will Never Be the Same
• AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD

LinkedIn is the best way to get in touch with Andrew.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Pharmacy Benefits 101: What's the Drug Management Program (DMP)?
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• Pharmacy Benefits 101: Medicare Star Ratings
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - JUDI®
• AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio Ciaccia

Learn more about Never Move Again™ HERE.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

This episode builds nicely on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.

Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"

Stay tuned for more, and we'll add some new resources (scripts and checklists, for example) to the links as they become available!

Related Content

• AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• Self-funded plans ignore the Consolidated Appropriations Act at their peril

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• Pharmacy Benefits 101: Medicare Star Ratings‍
• How Our Favorite New JUDI® Features Aid Pharmacy Benefit Administration
• How Our Favorite New JUDI® Features Aid Government Programs

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Research Results Show Promise Toward Development of a Universal Influenza Vaccine (Pharmacy Times; July 2024)
• Next-Generation Vaccines and Therapies for Seasonal Influenza
• Impact of the Inflation Reduction Act on Vaccinations: What Pharmacists Need to Know

Helpful Resources

• CDC Flu View - Weekly U.S. Influenza Surveillance Report
• CDC - What to Know About Flu Season

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

AH037 builds on Episodes AH027 and AH028 with Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration - our two-part What is Pharmacy Benefit Management? series that describes the importance of benefit design and configuration, as well as his webinar, The Story of a Claim. If you've ever wondered how products are developed and processes and workflows are refined to ensure medications reach patients smoothly and affordably or what a future with unified claims looks like, this episode is for you!

Related Content

• Replay – The Future of Pharmacy Claims Processing: A Deep Dive into a Modern Adjudication System
• Pharmacy Benefits 101: Prior Authorizations
• How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna
• GLP-1s are No Laughing Matter

Sources

• How many adults with private health insurance could use GLP-1 drugs (KFF; 9/5)
• GLP-1 Receptor Agonist Discontinuation Among Patients With Obesity and/or Type 2 Diabetes (JAMA; 5/24)
• Poll: 1 in 8 Adults Say They’ve Taken a GLP-1 Drug, Including 4 in 10 of Those with Diabetes and 1 in 4 of Those with Heart Disease (KFF; 5/10)
• The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028 (IQVIA; 5/7)

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Pharmacy Benefits 101: Prior Authorizations

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Since member service and support are central to Capital Rx's new Never Move Again™, as as AJ Loiacono describes in Episode 33 - Never Move Again™, a Paradigm Shift in Pharmacy Benefits, Will and host Justin Venneri dive into topics including:

• Client-specific training (e.g., cultural training)
• Why JUDI®, Capital Rx's enterprise health platform, is a "one-stop-shop" for Will's team
• The importance of considering how members will react to AI and automation
• Measures of success, including average speed of answer (ASA) and handle time

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 Capital Rx Insights.

• The program's transparent, flat-fee structure ensures no incentive to push more expensive drugs, leverage hidden markups, or otherwise profit at the plan's expense - aligning with the fiduciary duties under ERISA.
• JUDI Health is the solution's core, providing a fully integrated system that allows clients to use their preferred services - point solutions, other vendors, rebate aggregators, or even pharmacy network options.
• Never Move Again™ is a return to the original, independent role of PBMs, offering a more ethical and efficient future for U.S. healthcare.

Additionally, and please forgive the shameless plug, AJ joined Josh Golden, SVP of Strategy here at Capital Rx, who we spoke with earlier this year about future-proofing your pharmacy benefit plan (AH008), on September 19, 2024, at 2:00 PM ET for an educational webinar explaining our new offering: Build a Lasting Pharmacy Benefit Strategy with Never Move Again™.

Related Content

• 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
• ViVE 2023 Highlights: What's Behind the Price Tag of Medication
• AH032 - Prescription Rebates: Agreements, Guarantees, and More, with NPC's John O'Brien, PharmD, MPH, and Julie Patterson, PharmD, PhD

Learn more about Never Move Again™ HERE.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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

• Sign up for the NPC This Week Newsletter: https://www.npcnow.org/subscribe-updates
• Check out the National Pharmaceutical Council on LinkedIn
• Connect with John O’Brien, PharmD, MPH on LinkedIn
• Connect with Julie Patterson, PharmD, PhD on LinkedIn

Related Content

• Pharmacy Benefits 101: Pharmaceutical Rebates
• AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs
• Our Single-Ledger Model™ - Pharma Revenue Explained

Visit Capital Rx Insights for this episode's transcript and additional content!

Kristin and Mike suggest ways to update and improve legacy PBM evaluation methods, encouraging stakeholders to more carefully consider everything from the questionnaires leveraged to screen potential PBM partners to the true value of clinical programs for utilization management - such as prior authorization - and the actual number of units used to forecast spending.

Related PMPM Content:

• AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD
• PMPM - Is It the Best Way to Measure or Track Anything?
• PBM Procurement: A PMPM Guide for Plans Sponsors eBook

Visit Capital Rx Insights for this episode's transcript and additional content!

The Consolidated Appropriations Act (CAA) placed additional responsibilities on plan fiduciaries, including the need to make attestations. With gag clauses removed from contracts, the door is open. Jeff stresses the importance of analyzing the plan's data to make informed decisions and meet the fiduciary obligations. "The industry is craving trust," and fiduciaries need a trusted source of data and analytics to help them identify areas of waste and make changes that will benefit their plans. Whether it's pharmacy benefits, hospital spend, or the commissions paid to brokers/consultants, there's a unique opportunity to gain the insight needed and avoid the rising risk of liability right now.

To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.

Related Content

• AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• Self-funded plans ignore the Consolidated Appropriations Act at their peril

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Nick shares his insights on current market trends, such as the significant impact specialty drugs and GLP-1s are having on employers' overall plan spend. He also explains drug mix and how Capital Rx differentiates itself by leveraging JUDI® to maintain independence and administer aligned pharmacy benefit programs that meet clients' needs without the conflicts of interest that arise from owning dispensing assets and engaging in spread pricing., for example.

Related Content:

• The Upside of a Single-Ledger Model™ in Pharmacy Benefits
• AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna & How to Manage Pharmacy Benefit Spend in a GLP-1 World (Blog)

Please visit Capital Rx Insights for more information, including this episode's transcript!

Jillian and Jean also share their perspectives on the common challenges employers, for example, face when configuring and implementing a new PBM. They offer advice to ensure things go smoothly, emphasizing the importance of considering member experience. Last, Jean explains how JUDI's design enables the deployment of enhancements such as a new Medicare Prescription Payment Plan (M3P) solutions with relative ease.

Related Content:

• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• Government Programs: The True Meaning of Customization (with Jason Barretto)
• Pharmacy Benefits 101: Successful Implementations

Please visit Capital Rx Insights for more information, including this episode's transcript!

Jillian and Jean also share their professional journeys within the PBM industry, highlighting how their roles and teams are central to configuring and testing plan benefits so that formularies, the network, and clinical programs are set up correctly. This informative episode sets the table for a deeper dive into the configuration and testing that go on behind the scenes!

Related Content:

• AH001 - Building a PBM: Tech, Navigating Growth, and Delivering Value with AJ Loiacono
• What Is the Role of a Pharmacy Benefits Manager (PBM)?
• Pharmacy Benefits 101: What is a Formulary?

Please visit Capital Rx Insights for more information, including this episode's transcript!

Alfonso reviews several practical use cases and explains how an open platform like JUDI® is revolutionizing pharmacy benefits management without being too "salesy." Additionally, they touch upon the future potential of APIs in achieving value-based care by breaking down data silos and enabling integrated analytics, processing payments, and much more!

Related Content

• Capital Rx’s JUDI® - The Beauty of an Open Platform
• Capital Rx’s Enterprise Health Platform Enables Healthcare Organizations to Meet The CENTERS for MEDICARE & MEDICAID SERVICES’ M3P Requirements
• AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD

Please visit Capital Rx Insights for more information, including this episode's transcript!

Additionally, Krystalyn shares her thoughts on the importance of making progress at the federal level to allow pharmacists to be reimbursed by Medicare (ECAPS), the AMA's stance against the expansion of pharmacists' responsibilities, how to relieve the pressure on the pharmacy business model, what some pharmacies are doing to diversify their businesses and succeed, and much more.

Related Content

• AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC
• Iowa governor signs legislation that modernizes the state Pharmacy Practice Act
• Under new law, pharmacist scope of practice expands in Tennessee

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• AH015 - PBM Legislation, Contracting, and More, with Lloyd Fiorini
• 5 ways to improve your PBM procurement process in 2024
• Your PBM is the Problem
• Capital Rx CEO: PBM industry needs to be repaired, not ditched

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

• Pharmacy Benefits 101: Pharmaceutical Rebates
• Will Biosimilar Rebates Pass-Through?
• Pharmacy Benefits 101: Traditional vs. Pass-Through Models

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

How to Manage Pharmacy Benefit Spend in a GLP-1 World

GLP-1s are No Laughing Matter

Please visit Capital Rx Insights for more information, including this episode's transcript!

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

What is NADAC & How Does It Differ From AWP?

Why Use NADAC-Based Pricing Over AWP

Medicaid.gov - Drug Pricing (where NADAC lives)

Please visit Capital Rx Insights for more information, including this episode's transcript, AND we'll add links to any new studies or documents that may interest you if you're a student of drug prices or a fan of NADAC.

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 JUDI®, 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 Capital Rx Insights!

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 Capital Rx Insights.

Thank you for listening!

Last but not least, the team shares the most astonishing things they've seen around PAs, including a personal story!

For related content, check out:

• Pharmacy Benefits 101: What is a Formulary?
• Are Your Prior Authorizations Actually Working?
• Capital Rx's JUDI® Redefines the Role Tech Plays in the Administration of Medicare, Medicaid, and Commercial Pharmacy Programs (highlighting our new PAT)

For this episode's transcript and much more, please visit Capital Rx Insights.

Thank you for listening!

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 Capital Rx Insights for additional content, including this episode's transcript!

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

🏒 Replay: PBM Legislation: Navigating State and Federal Regulatory Changes and How They May Impact You

🏒 Self-funded plans ignore the CAA at their peril

🏒 For more information about M3P and Capital Rx's solution: Click Here

Please visit Capital Rx Insights for additional content, including this episode's transcript!

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:

• Yext Summit replay(s)
• Christian Ward on LinkedIn
• Carrie Liken on LinkedIn

Please visit Capital Rx Insights for additional content, including this episode's transcript!

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:

• A Virtual Care Blueprint - How Digital Health Technologies Can Improve Health Outcomes, Patient Experience, and Cost
• Travel ICU Nurse Concerns Across Covid-19 Hot Spots (NEJM)
• Robert's LinkedIn Profile

Please visit Capital Rx Insights for additional content!

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 Capital Rx Insights for this episode's transcript and additional content!

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

• Capital Rx’s Government Programs: Behind the Scenes with Jason Barretto
• Partnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management 
• JUDI® is a Tech-Enabler – A Case Study  

Visit Capital Rx Insights for this episode's transcript and additional content!

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

PMPM - Is It the Best Way to Measure or Track Anything?

PBM Procurement: A PMPM Guide for Plans Sponsors eBook

Visit Capital Rx Insights for this episode's transcript and additional content!

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

Prime Therapeutics and Capital Rx Create Technology Alliance

Capital Rx’s JUDI® - The Beauty of an Open Platform

Capital Rx Earns Surescripts® Certification & SOC 2 Type 2 Report

Visit Capital Rx Insights for this episode's transcript and additional content!

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

• Your PBM is the Problem
• Auto-Refill, Or Auto-Profit?
• Will Biosimilar Rebates Pass-Through?

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! 

Visit Capital Rx Insights for this episode's transcript and much more content from the Capital Rx team.

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 Capital Rx Insights.

For more information on these topics and this episode, please visit Capital Rx Insights or check out the linked content below!

1. Pharmacy Benefits 101: Medicare Star Ratings
2. What You Need to Know About 2024 CMS Translation Requirements

Thank you for listening!

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)!

Related Content: Self-funded plans ignore the Consolidated Appropriations Act at their peril

To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

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 www.cap-rx.com/insights for more!

For this episode's transcript and to learn more, please visit Capital Rx Insights!

Visit Capital Rx Insights for this episode's transcript and much more content from the Capital Rx team.