The Astonishing Healthcare Podcast

For Episode 96 of Astonishing Healthcare, Jason Barretto, our SVP of Government Programs, returns to the show for a discussion about what's happening on the health plan side of the business. As a company, we spend a lot of time talking about and showing how modern technology streamlines benefit administration workflows and overall operating efficiency, solves longstanding problems, and helps clients stay nimble to meet the intent of new regulations. Well, Jason's experience managing PBM relationships at health plans helps him - and our team - add real value when working with our clients. And, thankfully, he loves to talk...

Episode 95 of Astonishing Healthcare features six previous guests on the show who share astonishing observations from 2025 and some bold predictions for the New Year! Industry veteran Jeffrey Hogan, our General Counsel and Chief Compliance Officer, Lloyd Fiorini, ERISA law expert Nick Welle, two of our clinical leaders – Sarra Izadi, PharmD, Chief Clinical Officer, and Bonnie Hui-Callahan, PharmD, CDCES, Sr. Director, Clinical Programs, and our Chief Technology Officer and Co-Founder, Ryan Kelly, joined us for this round-robin discussion that’s packed with insightful reflections and optimism about the future.

We won’t ruin it in the show notes, but ba...

We got the ball rolling in 2025 with this episode, and it ended up at the very top of the activity list, so we'll close out the year with it as well! Thank you, Dr. Eric Bricker for joining 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 discussed the issues of high-cost drugs and access to claims data - two topics he covered on AHealthcareZ - Healthcare Finance Explained...

In this Best of '25! episode of the Astonishing Healthcare podcast, Lisa Ellerhorst (Sr. Director, Customer Care Operations) and Sonia Pettis (Manager, Customer Care Operations) discuss our approach to member care! 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 and benefits consultants often ask during the RFP process (Episode 84), this episode covers:

Episode 94 of Astonishing Healthcare features two members of our product team, Liya Lomsadze (Sr. Director) and Jake Mulkey (Director), who explain how building a next-generation pharmacy claim adjudication system (Judi®), known for its split-second accuracy and streamlined workflows, served as the perfect foundation for building a unified platform that now includes medical claims, and will integrate vision and dental, too. Liya and Jake explain the contrast between pharmacy’s real-time nature and medical’s weeks-or-months-long lag, and how this gap impacts the experience for members and providers of care.

The discussion covers the challenges behind supporting complex plan...

Episode 93 of Astonishing Healthcare features Susana Villegas Spillman, who brings over 20 years of health benefits plan management experience to the studio for a discussion about what works, what’s broken, and what employer plan sponsors deal with day in and day out. This “unfiltered perspective” from the plan sponsor’s seat is welcome and timely. If you’re one of the increasingly large percentage of benefits directors, CHROs, CFOs, et al. out there looking to transition from a traditional benefits experience to a new, transparent, aligned, unified model, this episode is for you!

Susana explains how a fragmented...

The level of interest in Episode 84 of Astonishing Healthcare made this one an easy choice to lift it to "best of" status. We'll be back with fresh new episodes in early December, and then we'll close out the year with two more Best of '25s. For those of you who didn't check this one out, Josh Golden, SVP of Strategy, and RFP Content Manager, Nic Bolitho, joined host Justin Venneri in the studio for a 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, b...

In this episode of Astonishing Healthcare, Judi Health's Sam Custer, who leads the member communications team, shares tips and insights on how to communicate effectively with plan members - around open enrollment and throughout the year. Sam last joined us for Episode 39, which highlighted how the communications and product teams collaborated to ensure we provide clear, compliant communication materials to Medicare members to meet CMS requirements, and this time, we dive into how to educate plan members at open enrollment and throughout the year. After all, as Marsha Perry, our head of benefits and compensation, explained during Episode 72 - The Benefits You Probably Didn't Know You Have, benefits-related education is more than just a once-a...

On Episode 91 of Astonishing Healthcare, we dove into the Workplace Intelligence Forecast for 2026 - The 10 Trends Businesses Need to Focus On! Here at Judi Health, we obviously live in the health benefits world and generally focus on content revolving around the pharmaceutical supply chain (i.e., PBM), health tech, and the administration of employee benefits, more broadly... but there is A LOT more going on our there that impacts America's workforce. Our guest, Dan Schawbel, Managing Partner of Workplace Intelligence (links below), has been tracking and publishing research on workplace trends for well over 15 years, and he unpacks the...

For Episode 90 of Astonishing Healthcare, Jim Winkler, Chief Strategy Officer at Business Group on Health, joins us in the studio for a lively discussion about the results of their 2026 Employer Health Care Strategy Survey! This annual study is packed with qualitative and quantitative information and highlights the top trends in employer-sponsored health care. Jim brings decades of experience to the table and puts helpful context around the headline data and employers' expectation for a ~9% year-over-year health care cost increase. He also shares his perspective on the evolution of the role benefits brokers and consultants play, how employers can navigate...

On Episode 89 of Astonishing Healthcare, we are talking about some "visual treats," as the title suggests! Our guest, Andrew Tsang, has been posting some very cool things on LinkedIn of late, including Sankey and other dynamic charts highlighting where the money flows in healthcare (from the premium dollars to the care plan members receive), and which stakeholders win or lose in different scenarios via a 5-Way Seesaw he developed using AI! If you're a [healthcare] data nerd, this episode is definitely for you, and you'll want to check out:

On Episode 88 of Astonishing Healthcare, we're celebrating Women Pharmacist Day (#WPD2025) and sharing stories from four of our amazing team members: Allison Gallant, PharmD (Sr. Strategic Account Executive), Cindy Strassner, RPh (Customer Success Pharmacist), Lorece Shaw, PharmD (Sr. Director of Prior Authorization and Clinical Care), and Hope Nakazato, PharmD (VP of National Business Development). These women aren't just talking about improving healthcare or celebrating one day - they're actively promoting and implementing change, mentoring the next generation of pharmacists, and building systems to improve clinical workflows and member care.

Lorece, Allison, Hope, and Cindy highlight their career...

In this episode of Astonishing Healthcare, return guest Libbi Green, PharmD (Manager, Formulary Operations) joins Justin Venneri for a discussion about the 2025 flu season, including the latest vaccine-related updates that employer plan sponsors and plan members need to know. We discuss the effectiveness of last year's flu vaccines, factors influencing the rates, vaccination timing, and how there can be differences in state vs. federal guidelines, among other topics!

Highlights

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:

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:

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...

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.

Highlights

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 tru...

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...

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 hea...

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 not...

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 w...

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 de...

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 memb...

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...

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 de...

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...

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...

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...

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 pict...

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 pay...

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.

...

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 appropria...

In this episode of the Astonishing Healthcare podcast, Justin Venneri speaks with Kristin Begley, PharmD, Chief Commercial Officer at Capital Rx, about the evolving role of Pharmacy Benefit Managers (PBMs) and the rapidly accelerating shift in demand for an "unbundled," agnostic model. But what does unbundling mean? How does this approach help to avoid conflicts of interest? What parts of a pharmacy program can be carved out or unbundled to allow plan sponsors the freedom to design a plan that meets their unique populations' needs? Kristin answers these questions and more during the conversation, and she also explains what's so astonishing about the Trump administration's executive order aimed at addressing global drug pri...

In this episode of the Astonishing Healthcare podcast, Mike Tate, one of the newest members of Capital Rx's commercial team, joins Justin Venneri in the studio to discuss the latest challenges and innovations in the healthcare market, and how he's approaching growth opportunities "west of the Mississippi." Mike explains why his region has been relatively slow to adopt self-funding strategies compared to the rest of the country (despite the great work of innovative brokers and consultants), how plan members - who are more informed than ever before - are pushing their employers' benefits teams to think creatively about their...

This episode of the Astonishing Healthcare podcast with Dr. Sunil Budhrani (Chief Innovation & Medical Officer) highlights the transformative potential of Judi Health™, the first Unified Claims Processing™ platform offering a combined medical and pharmacy benefit experience (with vision and dental soon to follow)! Why is unifying claim administration necessary to reach a value-based world? Well, everyone has been talking about VBC for years, and it's proved to be an elusive target. On Episode 7, Dr. Budhrani explained why pharmacy must be included in the equation along with providers, patients, and payers, and today we go a level deeper, explaining why "ever...

This Astonishing Healthcare podcast episode features Bridget Mulvenna, who joins us in the studio again for an insightful discussion about addressing data access hurdles and utilizing pharmacy claims data. Building on her previous episodes, we dig into the "how" here - how can plan sponsors get their data, analyze it, and use it to make more informed decisions. It's encouraging that things are getting a little better out there, but data transparency and sharing remain top concerns for channel partners and plan fiduciaries alike; everyone is trying to understand what's driving costs higher within their plans (aside from GLP-1...

In this episode of the Astonishing Healthcare podcast, we welcome Jessin Joseph, PharmD, MBA, back to the studio. Jessin's focus on the pharmacy benefit administration side of the business and experience at Kentucky Medicaid and working with health plan clients inform the discussion about the impact the new administration and appointments in Washington, D.C., may have on health plan partners, MPPP (M3P), various models of Pharmacy Benefit Management (PBM) for Medicaid, including the single PBM and carve-out/unbundling approaches, and how the drug price benchmark can influence access to medication for plan members.

In Episode 16...

This encore episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Judi Health garnered much attention during our second annual Partner Summit, as Unified Claims Processing™ has the potential to help reduce up to $1 trillion of administrative waste and empower the provider-patient relationship.

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 mode...

In this episode of the Astonishing Healthcare podcast, Spencer Kramer, Director, Client Services at Capital Rx, joins us in the studio to discuss an important aspect of plan sponsors' annual reporting requirements: Prescription Drug Data Collection - aka RxDC. We review key dates and where plan fiduciaries can find important data and updates, and Spencer shares his experience working with Capital Rx's clients and some suggestions to a) yield a smooth RxDC submission process and b) make use of the detailed data that plan sponsors are entitled to!

As a requirement of the Consolidated Appropriations Act of 2021...

On this episode of the Astonishing Healthcare podcast, we discuss how modern technology - Judi® - brings efficiency to the labor union market with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services), Christie Peperato (Manager, Payment & Operations), and Kelly Smith (Product Manager). Who knew that Capital Rx has an hours banking system? Why did we build one? Well, every hour a union worker works may be tracked and "banked" for benefits eligibility purposes. So, those hours and the accuracy of the reporting matter... a lot. And as Christie describes, it's been a manual, "painful" process f...

For this special episode of the Astonishing Healthcare podcast, Andrew Barnell, CEO of Geneoscopy, joins Justin Venneri in the studio for an insightful discussion about colorectal cancer (CRC) screening in observance of National CRC Awareness Month! Andrew explains how he and his "very talented" sister, Erica Barnell, MD, PhD, co-founded Geneoscopy to develop diagnostic tests using RNA biomarkers extracted from stool samples. Their newly FDA-approved test, ColoSense™, provides a non-invasive alternative to traditional colonoscopies.

Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses th...

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

On this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. They dive into several 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:

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

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

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 - m...

On this episode of the Astonishing Healthcare podcast, we explore the nuances of stop-loss insurance with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services). With premiums on the rise due to high-cost claims reaching levels actuaries never thought possible, self-insured plan sponsors need new options and better tools to monitor their costs. Mike, who is a healthcare actuary by training, discusses everything from "What is stop-loss?" and who it's for to what's driving high-cost claims to new heights, the rise of a pharmacy-only stop-loss option, and options plan sponsors have to mitigate risk when "it's...

This episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Guests AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively.

Building on Episode 7 (with Sunil) and Ep...

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

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

They...

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

A former pharmacy owner himself, Nick explains the importance of helping hospice providers...

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

Hope uses the book, "Who Moved My Cheese?", by Dr. Spencer Johnson, to explain the fear of change, as well as three things people can look...

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

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...

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...

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...

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...

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...

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...

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:

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 o...

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...

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 t...

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 f...

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...

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...

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, S...

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...

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. Duration: 00:23:54

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

Together, they explore the importance of appropriate...

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

The conversation delves into the different types of clinical programs offered by Capital Rx...

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

Since member service and...

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

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

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

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

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...

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

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

Jillian and Jean also share their pe...

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

Jillian and Jean also share their professional journeys within the PBM i...

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

Alfonso reviews several practical use cases and explains how an open platform like JUDI® is revolutionizing pharmacy benefits management without being too "salesy." Additionally, they touch upon the future p...

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

Additionally, Krystalyn shares her thoughts on the importance of making progress...

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

Ryan and Josh also stress the importance of...

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

Heidi underscores the need for a sound compliance framework to support business growth and meet evolving regulatory...

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

With market dynamics rapidly changing, Episode 22 offers valuable insights into the evolving landscape of...

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

Plan sponsors must work closely with pharmacy benefits managers (PBMs) and dive...

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

NADAC serves as...

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

She addresses concerns surrounding GLP-1s, specifically the expanded FDA...

On this episode of the Astonishing Healthcare podcast, a trio of pharmacists on the Capital Rx team join Justin Venneri and share their experiences and insights related to the residency and fellowship programs (i.e., post-graduate training) that pharmacists often choose to participate in. Allison Gallant, PharmD, Caitlyn Tung, PharmD, MBA, and Nicole Bergman, PharmD, discuss the details of well-designed programs that foster personal and professional growth, the array of traditional and non-traditional settings pharmacists can practice in, what the residency program at Capital Rx - a pharmacy benefit manager (PBM) - looks like, the difference between accredited and...

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

Last but not least, the team shares the most...

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

Jessin highlights the changing rebate landscape for Medicaid (and Medicare) plans, the financial implications of M3P...

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

Beyond the CAA a...

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

The conversation delves into...

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

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...

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

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, Ca...

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

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 th...

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

Capital Rx Co-Founder and Chief Technology Officer Ryan Kelly joins Justin Venneri for a discussion about the opportunity to bring efficiency to an industry reliant on "horrendously and horribly inefficient" technology and the benefits that modern technology can bring to the administration of a pharmacy benefit program. Some benefits include centralizing all operational workflows and health information in one platform (JUDI®) and data security in the wake of recent cyberattacks. 

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 as...

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

Josh explains the importance of a...

In this episode of the Astonishing Healthcare podcast, Dr. Sunil Budhrani, Chief Innovation and Medical Officer at Capital Rx, discusses the intersection of value-based care and pharmacy. He explains the concept of value-based care in a clear and relatable way and describes how it has evolved over the years. Dr. Budhrani, who remains an active ER physician, shares his experiences from different roles across the healthcare system and highlights the fragmentation and silos that hinder the progress toward a true value-based care system.

He emphasizes the importance of sharing data and integrating pharmacy in value-based care programs...

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

Amy also mentions the team's involvement in the Ca...

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