The Astonishing Healthcare Podcast

Episode 86 of the Astonishing Healthcare podcast focuses on several pharmacy and health plan member service-related topics with Lisa Ellerhorst (Sr. Director, Customer Care Operations) and Sonia Pettis (Manager, Customer Care Operations)! Lisa and Sonia have been with Judi Health (Capital Rx) since 2020 and have helped Will Tafoya develop our unique contact center model from the ground up. Building on Episode 34 - Customer Care in Healthcare: Setting a Higher Bar, and the questions plan sponsors can ask during the RFP process (Episode 84), we discuss: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 ContentPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchWatch: Are Your Prior Authorizations Actually Working?AH017 - Pharmacy Benefits 101: Prior AuthorizationHow employers can take back control of unnecessary pharmacy spendingCapital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer ServiceFor more information about Capital Rx and this episode, please visit Judi Health - Insights.

This episode of the Astonishing Healthcare podcast features a unique client of ours - Andy Glade, Senior Director of Trade Operations at Valeris. We discussed how to remove financial barriers to care and streamline access to the medications people need through the use of copay cards, vouchers, and patient assistance programs (PAPs). In a rapidly evolving market, these programs play an important role in reducing prescription abandonment and increasing adherence in convenient ways, particularly for chronic conditions and when extremely expensive specialty medications are prescribed.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 Content12 New Judi® Features Innovating Pharmacy Benefit AdministrationReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better OutcomesAH081 - Promoting Competition & Innovation: The Push for PBM Reform, with Rep. Jake AuchinclossHealth Benefits 101: The Importance of a Transparent PBM ModelReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactFor more information about Capital Rx and this episode, please visit Judi Health - Insights.

In this episode of the Astonishing Healthcare podcast, host Justin Venneri is joined by Josh Golden, SVP of Strategy, and RFP Content Manager, Nic Bolitho, for a timely discussion about trends they're seeing in the market and how to run a better request for proposal (RFP) process to select a pharmacy benefit management (PBM) partner. Long story short, the "old way" of running a PBM RFP is broken, but, as Josh describes, there are some "tectonic shifts" happening as plan sponsors demand to see more options (i.e., transparent PBMs) and benefits brokers and consultants upgrade the questions and scoring used to force accountability and drive meaningful results for plans and plan members.HighlightsUnit-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 ContentReplay: 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 TafoyaAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD5 ways to improve PBM procurement (EBN) For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Episode 83 of the Astonishing Healthcare podcast features returning guest, Bridget Mulvenna (VP, National Business Development at Capital Rx)! We discuss specialty drugs, pharmaceutical manufacturer rebates, and the shift to biosimilars. Yes, GLP-1s come up as well (how could they not?), and Bridget explains how employer plan sponsors can consider opportunities to provide access to these medications while not ignoring their inflationary potential and the economic impact on the plan - i.e., how to pivot from a rebate-driven models to a net-cost approach, facilitating more accurate cost management and budgeting.HighlightsTraditional 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 ContentWill Biosimilar Rebates Pass-Through?Health Benefits 101: The Importance of a Transparent PBM ModelHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldPharmacy Benefits 101: What is a Formulary?Pharmacy Benefits 101: Pharmaceutical RebatesFor 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 BrickerFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Tracey Rollins, CPM (Sr. Director, Client Implementations) and Kristen Morgan (Director, Health Plan Implementations) join Justin Venneri in the studio for a discussion about pharmacy benefit implementations and how switching to an aligned, transparent partner can be efficient and a pleasant experience, despite the complexities involved.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 ContentPharmacy Benefits 101: Successful ImplementationsSigns it is time to change your PBM vendor, and how to overcome common hesitationsReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better OutcomesWhy Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBookFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This special episode of the Astonishing Healthcare podcast features Congressman Jake Auchincloss, who discusses his efforts to reform pharmacy benefit managers (PBMs) and address systemic issues in the U.S. healthcare system to bring down costs. Representing Massachusetts' 4th district and growing up in a family of medical professionals and scientists, Rep. Auchincloss draws on his experience to advocate for policies that promote competition, innovation, and improved access to affordable care. He highlights his Pharmacists Fight Back Act (H.R.9096), noting that he looks forward to reintroducing the widely supported, bipartisan bill that aims to protect independent pharmacies, employers, and plan members, and he shares optimism about the potential for meaningful PBM reform to become law.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'?HighlightsMandatory 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 ContentThe 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 WelleRELEASE: AUCHINCLOSS INTRODUCES BIPARTISAN PHARMACISTS FIGHT BACK ACT TO CRACK DOWN ON PREDATORY DRUG PRICINGWhat is NADAC & How Does It Differ From AWP?For more information about Capital Rx and this episode, please visit Capital Rx Insights.

Episode 80 of the Astonishing Healthcare podcast focuses on care navigation! Our guest, Andy Kageleiry (VP, Judi Care), explains the role of care navigation in helping health plan members (i.e., healthcare consumers) find care and navigate the complex U.S. healthcare system. He also discusses the importance of care navigation from the perspective of a plan sponsor. While everyone in the healthcare industry talks about patient-centered care and controlling costs, patients are left to navigate fragmented systems that work against them. Andy cuts through this contradiction and explains how care navigation can help as a core piece of the health benefits puzzle.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 HighlightsTrue 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 ContentCapital Rx Acquires Care Navigation Company Amino HealthHealth Benefits 101: The Importance of a Transparent PBM ModelAH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil BudhraniPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchReference ArticlesSame 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.

In this episode of the Astonishing Healthcare podcast, Mike Miele, FSA, MAAA (SVP of Insured Services), joins us again for a lively discussion about a new product and the growth of level-funded pharmacy plans. What are level-funded plans? How does Capital Rx's "Capital Equilibrium" work? Listen in to hear how these plans, positioned between self-funded and fully insured models, offer employers budget certainty while maintaining flexibility and transparency. Mike highlights the scenarios where a level-funded plan can truly help - e.g., a municipality with a fixed budget and the role stop-loss plays (building on Episode 55), and he also notes that not all level-funded plans are equal, and plan sponsors should look for transparency around rebates and whether any savings - if a plan's performance is better than the guarantee - ultimately benefit the plan.Related ContentAH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael KleinrockPharmacy Benefits 101: Pharmaceutical RebatesAH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmDHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, Capital Rx's Dr. Sunil Budhrani (Chief Innovation & Medical Officer) and Mike Tate (Vice President, National Business Development) discuss the questions they are fielding from channel partners and prospects interested in Judi Health™ - the first unified medical and pharmacy solution. We explore advancements in unified claims processing and how it helps address healthcare's fragmented nature by integrating pharmacy and medical benefits data with preferred vendors to tackle specific needs (e.g., for women's health or chronic condition management). Sunil also shares early, updated data revealing a ~5% per-employee-per-month (PEPM) reduction in costs YTD with Judi Health compared to 2024. Additionally, the conversation with Sunil and Mike covers:The importance of empowering patient-provider relationshipsThe need for greater transparency and access to data to see what's driving costsHow a platform that allows for flexibility and personalization helps lower costs and provides for a better member experienceRelated ContentJudi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactHealth Benefits 101: The Importance of a Transparent PBM ModelReplay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based CareFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, host Justin Venneri sits down with Lauren Carroll, PharmD, a Senior Clinical Programs Manager at Capital Rx, to discuss Rx Retro, a pharmacist-led program that focuses on medication deprescribing to enhance patient safety, reduce adverse drug events, and improve healthcare outcomes. Lauren shares insights into how Rx Retro leverages Judi® - Capital Rx's enterprise health platform - to identify and address drug therapy concerns through a series of alerts and outreach designed to promote the safest and most effective treatments for plan members. The conversation also highlights the broader implications of deprescribing for healthcare quality and cost savings, with Lauren noting that, "We are uniquely positioned to bridge gaps that exist in the healthcare system."HighlightsDeprescribing 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, PharmDPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDPharmacy 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, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this episode of the Astonishing Healthcare podcast, we discuss recent health policy news and how to bring greater transparency to health benefits programs with returning guest, Jeff Hogan, President of Upside Health Advisors. Building on our previous discussion with Jeff - How First-Movers are Taking Control of their Health Plans in 2025 - we shed more light on the “PBM boogeyman” narrative, explaining how opaque pricing structures and unhelpful provisions buried in contracts must be discovered. Jeff reviews attempts by states around the country to intervene and halt steering and other practices that negatively impact health plans and their members - from early medical reform efforts to recent PBM-focused legislation. He also notes Medicaid cuts are likely to have some "second-order effects" that impact commercial plans, and the mood in Washington, DC, overall is "dazed and confused," so we can't count on help at the federal level.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 ContentCapital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing PlatformSigns 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 ImpactTo 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.

In this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Lindsey Butler, PharmD, Vice President & Clinical Pharmacy Consultant at Lockton, and Chris England, Vice President of National Business Development at Capital Rx. They discuss what health systems need from a pharmacy benefit management (PBM) partner, the challenges in today's market, and the opportunities for innovation and collaboration to advance care for the patients in the communities health systems serve. State-level regulatory changes are top of mind, and Lindsey explains what she's tracking and how she's approaching meeting her clients' unique requirements: How can the benefits program aid with talent acquisition and retention? Can a pharmacy program meet everyone's needs (from the C-suite to the pharmacy team)? Both guests share insights from their extensive experience, offering ideas for health systems to enhance their pharmacy programs and improve the health benefits and healthcare experience for employees and communities.HighlightsArkansas 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 ContentPharmacy 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 HookPharmacy Benefits 101: The Importance of the NetworkTo get in touch with Lindsey: Lindsey Butler, PharmD, CSPPlease visit Capital Rx Insights for more information, including this episode's transcript!

On this episode of the Astonishing Healthcare podcast, Carrie Liken (now with Snowflake) returns to the show to discuss the exceptionally rapidly evolving search landscape and Google's new AI Mode. Are websites dying as AI-powered search ascends in popularity? According to Carrie, it looks that way. She and host Justin Venneri discuss the transformative impact of AI on healthcare search and patient journeys. They explore how tools like Google’s new AI Mode and ChatGPT are reshaping how consumers find healthcare information, reducing reliance on traditional websites. Carrie shares insights from her "mini research studies," highlighting the challenges and decisions healthcare organizations face in adapting to the new world.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 MaterialsMaybe 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, TodayFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

The latest episode of the Astonishing Healthcare podcast dives into the functionalities and real-world impact of Rx Smart Save, a low-cost alternative program designed to reduce medication costs for both patients and plan sponsors. Jackie Lolos, PharmD, and Haleh (Halls) Campbell, PharmD, join Justin Venneri in the studio for a discussion highlighting the innovation and care behind this clinical program.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 ContentAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDSigns 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.

On Episode 72 of the Astonishing Healthcare podcast, Marsha Perry, Capital Rx's Head of Benefits and Compensation, joins host Justin Venneri in the studio for a conversation about the intricacies of employee benefits, beyond pharmacy benefits! At a high level, she shares her thoughts on setting up a "well-rounded and affordable" benefits package, what should be in the benefits guide, and how to drive app usage and engagement in underutilized programs (a little humor and sharing personal stories almost always helps 😀).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 ContentReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactAH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget MulvennaReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better OutcomesPlease visit Capital Rx Insights for more information, including this episode's transcript!

This episode of the Astonishing Healthcare podcast features Michael Kleinrock, Director, Research Development at the IQVIA Institute for Human Data Science. We explore key highlights from their most recent annual report - Understanding the Use of Medicines in the U.S. 2025 - with an eye toward implications for plan sponsors and the health benefits market. What are the key drivers of higher drug spend beyond GLP-1s? At what cost do consumers abandon prescriptions at the counter? How is biosimilar adoption going, and what impact is it having on trend? We answer these questions and many more, including how the IRA could impact innovation, vaccination rates, and what was most surprising to Michael in the data: hint, it's how much prices really changed year-over-year! Additional Reference Materials (IQVIA Institute Reports & Publications)Assessing the Biosimilar Void in the U.S.Proliferation of Innovation Over TimeRelated ContentAH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric BrickerAH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAAReplay - Innovative partnerships for GLP-1 management, with Vida HealthHow to Manage Pharmacy Benefit Spend in a GLP-1 WorldFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This "Best of '25!" episode of the Astonishing Healthcare podcast highlights Episode 58, which featured Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. We'll be back with a fresh new episode next week, but given the acquisition of Amino Health and launch of Judi Care, a unified "front end" pharmacy and medical care navigation solution, we think having an understanding of what the back end - or "chassis" - is capable of helps paint a picture of what the future of health benefits management can look like!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 ContentCapital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing PlatformCapital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®How Our Favorite New JUDI Features Aid Pharmacy Benefit AdministrationAH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2For more information about Capital Rx and this episode, please visit Capital Rx Insights.

In this special episode of the Astonishing Healthcare podcast, Capital Rx Co-Founder and CEO, AJ Loiacono, and John Asalone, Executive Vice President of the newly formed Judi Care (former CEO of Amino Health), join Justin Venneri in the studio for a discussion about Capital Rx's acquisition of Amino, a unique care navigation company. The conversation covers everything from the background on how AJ and John met to "What is care navigation?" and how Judi Care offers 1) health plan members (i.e., healthcare consumers) a differentiated way to take control of their individual healthcare journeys, and 2) plan sponsors and other payers a user-friendly, unified pharmacy and medical care navigation front end that empowers plan members to find the care they need, when they need it.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 ContentJudi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramCapital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing PlatformCapital Rx Adds More than 80 New Partnerships in 2024 and Eyes Another Year of Record Growth in 2025AH065 - The Bridge to Value-Based Care: Unified Claims Processing™, with Dr. Sunil BudhraniFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

This episode of the Astonishing Healthcare podcast highlights two recent posters presented by Zachary Brunko, PharmD (PGY1 Managed Care Pharmacy Resident), and Nash Albadarin, PharmD, MBA (Associate Director, Clinical Programs Business Development), at AMCP 2025 and the 2025 PQA Annual Meeting, respectively. 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 ContentPoster: 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 PopulationAH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmDAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDPlease visit Capital Rx Insights for more information, including this episode's transcript!

This episode of the Astonishing Healthcare podcast is all about Pharmacogenomics (PGx), a critical component of precision medicine that ensures the medications prescribed to patients align with their genetic makeup.. To explain everything from what PGx is and barriers to broader adoption to the future state of integrated care, Burns Blaxall, PhD (Senior Vice President of Precision Medicine at Aranscia), and Caitlin Munro, PharmD (Sr. Clinical Programs Manager at Capital Rx), joined Justin Venneri in the studio.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 MaterialsValidation of Pharmacogenomic Interaction Probability (PIP) Scores in Predicting Drug–Gene, Drug–Drug–Gene, and Drug–Gene–Gene Interaction Risks in a Large Patient PopulationAH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmDAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmDAH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmDFor more information about Capital Rx and this episode, please visit Capital Rx Insights.