The Astonishing Healthcare Podcast

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.

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

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.

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

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.

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

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.

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

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.

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

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.