Capital Rx Insights (May 2024)

Pharmacy claims are uniquely complex, but processing a pharmacy claim is often seen as a straightforward task. Why is that? Claim adjudication is arguably one of our healthcare ecosystem's most critical and intricate workflows. Join us for The Story of a Claim and hear Capital Rx’s Vice President of Product Management, Kevin Sundquist , illuminate the journey of a claim in a modern enterprise health platform, JUDI? .

He’ll answer your questions and explain what starts the adjudication process, the importance of the benefit design and formularies, what happens when prior authorization (PA) is required, how real-time processes reduce turnaround times, and much more.?

Click here or on the image below to register for the webinar!

Related Content?

?? Pharmacy Benefits 101: What is a Formulary? ?

?? MTVA Unscripted: Unraveling the Complexities of Pharmacy Benefits with AJ Loiacono ?

? What is the Role of a Pharmacy Benefits Manager (PBM) ??

Read on for the usual roundup of news and insights from the Capital Rx team, including how to manage GLP-1 spend , our most recent Astonishing Health episodes, IQVIA’s latest Use of Medicines report, and much more.

Astonishing Healthcare

If you haven’t yet, visit our Astonishing Healthcare Podcast page or subscribe on Apple or Spotify!??

May 2024 Episodes?

• AH020 - Why NADAC is a "Ray of Sunshine," with A. J. Loiacono and Antonio Ciaccia (5/31)

• AH019 - Wrestling with Coverage of High-Cost CGTs, GLP-1s, and How to Meet Regulators' Intent, with Casey Stockman, PharmD (5/24)?
• AH018 - What's the Right Path? Post-grad Options for Pharmacists with Allison Gallant , PharmD, Caitlyn Tung, PharmD, MBA , and Nicole B. (5/17)?
• AH017 - Pharmacy Benefits 101: Prior Authorization with Sara Izadi, PharmD , Lorece Shaw, PharmD , and Callie Burton-Callegari (5/10)?
• AH016 - The Intersection of Pharmacy, Government Requirements, and Medicaid with Jessin Joseph (5/3)?

Knowledge Exchange?

• In How to Manage Pharmacy Benefit Spend in a GLP-1 World , Capital Rx’s Bridget Mulvenna shares her insights on controlling GLP-1-related costs based on her 30+ years of experience in the pharmacy industry. This class of drugs deserves special attention, and she acknowledges the challenges and unique considerations plan sponsors must work through.?

• Lauren Carroll , PharmD, BCACP; Angela Kalantarova, PharmD ; Brigitte Kinsey ; Bonnie Hui-Callahan, PharmD, CDCES ; Jay Tran , PharmD, MHA; and Sara Izadi, PharmD , conducted a study and presented the results at the PQA Annual Meeting: Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use .?

• Our clinical team published its Drug Pipeline & Clinical Update - April 2024 , highlighting key new drug approvals, including Ojemda? (torarafenib) for pLGG, the most common brain tumor diagnosed in children, and three notable expanded indications, including Fanapt? (iloperidone) for acute treatment of bipolar I disorder.?

• At the end of April, Capital Rx Co-Founder & CEO A. J. Loiacono was a guest on MedCity’s Pivot Podcast . He explains why Capital Rx built JUDI? and the flexibility and workflow improvements this modern enterprise health platform offers. It's time for a sea change - we must upgrade this country's infrastructure to provide the healthcare we deserve.?

Consultant Corner: It’s Your Data!?

Channel Partners,? ?

While meeting many plans with their brokers/consultants in late April and throughout May, one hot topic - and cause of frustration - has been the time it takes to get detailed reporting from PBMs. An example that stood out to me was a request for a relatively simple data set. The PBM took over 30 days to get the necessary reports the plan was looking for together and deliver them. This ultimately put pressure on the HR team because they needed to deliver the highlights to the executive leadership team, and we all know how we feel when we have a deadline to present data and don't have exactly what we need, right??

?In my experience, a request like the above shouldn't take that long. With JUDI? , not only can we pull reporting quickly, but plans and their brokers/consultants have the ability to access self-reporting, which cuts down the time it takes to access data. Our Data Output & Reporting tool is one of my favorite?newer JUDI features ?because it isn't just another example of how modern technology helps plans and consultants access their data when needed to make informed decisions and recommendations; it's also an example of business model alignment and an understanding of what's required to offer a better pharmacy benefit experience.?

Let me know if you’d like to chat.?

Brian?

Brian TenEyck , National Director, Consultant Relations || [email protected]

Most Read News at Capital Rx?

• The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028 (IQVIA; 5/7)?
• Assistant Attorney General Jonathan Kanter Announces Task Force on Health Care Monopolies and Collusion (OPA, US DoJ; 5/9)?
• House Committee Proposes to Extend Medicare Telehealth Flexibilities, Eyes PBM Reform to Offset Expenses (Mintz; 5/15)?
• Centivo acquires virtual-first medical provider Eden Health to expand its reach with employers (Fierce Healthcare; 5/20)?
• Prescription drug ads should soon start looking noticeably different (Axios; 5/20)?
• How the Ascension cyberattack is disrupting care at hospitals (NPR; 5/23)?
• Ozempic keeps wowing: trial data show benefits for kidney disease (Nature; 5/24)?

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