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

Dr. Bricker shares several ways employers, depending on their size and risk tolerance, may be able to navigate the challenge of rising pharmaceutical costs for orphan and other expensive drugs - including GLP-1s. He also explains how the RFP process can be used to secure the plan's claim data, which is necessary to meet fiduciary obligations.

While every plan is unique, most plan sponsors face similar challenges that the traditional PBM model isn't flexible or aligned enough to solve. Dr. Bricker is astonished by the complacency out there, but he does see the potential for an acceleration in the pace of change this year and next... tune in to hear why, and check out the links below for more information!

AHealthcareZ Reference 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!

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

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

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

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

Related 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.

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

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

Related 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.

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

Robert shares the highlights of his analysis, including what he found most interesting and what he'll be watching for on payment policy (e.g., there's bipartisan support for payment reform and price transparency), potential changes to Medicare Advantage and Medicaid, pediatric care, how to reduce administrative burden and alleviate provider burnout, abortion policies, the use of artificial intelligence, and access to patient data. If health policy matters to you, this episode is a "must-listen!"

Related 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.

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

Tom has helped hundreds of drug manufacturers launch, acquire, or divest assets and bring products from the regulatory phase to commercialization, so he's seen a lot and pays close attention to issues impacting drug prices and market access. Given his broad experience across the pharmaceutical supply chain, almost no topic is off the table. The conversation dives into the Inflation Reduction Act (IRA), the Chevron Ruling and 340B program, AI, why rebates likely aren't going anywhere soon, and the most astounding thing Tom's seen (hint: it relates to GLP-1s)!

Related 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.

Our first "Best of" Astonishing Healthcare podcast episode goes back to the beginning. For those who have been listening, "Thank you!" - we'll be back with a new episode next week. For new listeners, A LOT has happened since our co-founder and CEO AJ Loiacono kicked things off, including, but not limited to:

• New York City FC and Capital Rx Announce Sleeve 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.

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

Nisha also dives into how specialty drugs fit into the equation, utilization management tools like prior authorization (PA), the role of formularies in helping manage low-cost generic or high-cost brand lists, and more!

Related 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.

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

Why is payment expected regardless of a correct diagnosis? Does insurance need to be so confusing? Can the RFP process help set rational expectations? What's the best way to conduct primary research when everyone's time is at a premium? Andrew answers these questions and many more during today's discussion!

Related 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.

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

Additionally, Nash highlights the utility of these programs and their potential beyond the government sector, as MTM and mitigating the risks associated with opioids, for example, can help other plan sponsors better manage their populations.

Related 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.

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

Kasi expertly breaks down this subject, covering everything from the basics to building a NADAC-based commercial network, adding pharmacies to the network, the importance of transparency and independence (i.e., not owning dispensing assets), and how clients weigh cost vs. quality. She also explains how our agreements and networks are like Legos® (for Never Move Again™)!

Related 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.