Capital Rx
In 2023, we detailed eleven of our favorite Judi® features – 9 that aid pharmacy benefit administration broadly and 2 focused on government programs. With another year having passed, we have a new batch of features specifically designed to help plan sponsors manage their pharmacy programs, bring transparency to an obfuscated industry, and redefine what’s possible within healthcare claim administration.
To learn more about how these features work and what makes them important tools, we spoke with one of our Product Directors, Liya Lomsadze, who eloquently detailed each of the 12 updates and their utility.
#1 - Third Party Administrator (TPA) Eligibility Module
Judi’s TPA eligibility module takes member inputs – like demographic info, employment history, and life events – and uses this data to determine a member’s eligibility for health benefits. Users can also configure the module to look for other unique thresholds to determine eligibility (i.e., working a certain number of hours or being employed for a certain amount of time).
Judi then transmits these eligibility files to various downstream vendors, including medical, dental, and life insurance, serving as a source of truth for all member enrollment.
Why this feature matters:
Intaking and tracking the hours submissions, payments, and eligibility rules from numerous entities for union members and their dependents, for example, can be challenging and extremely manual. The TPA Eligibility Module centralizes and simplifies the management of union members’ eligibility.
#2 & 3 - Updates to Our Prior Authorization Tool
Judi’s Prior Authorization Tool underwent a couple of different updates throughout 2024.
First of all, this tool now enables the intake and review of Medicare and Medical PA cases from external users. This update also provided additional features, like auto-populating authorization information and enabling users to create more than one authorization at a time.
Additionally, the Capital Rx team added a supervisor dashboard, which allows PA supervisors to quickly evaluate PAs and direct reviewer resources, streamlining a complex process and increasing efficiency during PA review.
Why This Feature Matters:
There is a dual benefit to ensuring PA reviews are completed in a timely manner: it keeps members and providers informed and it keeps PA teams compliant. Supervisors who manage teams of pharmacy technicians and pharmacists need visibility into request volume and flow to manage their resources, and this tool enables that visibility.
#4 - Data Output & Reporting
Our Data Output & Reporting tool received significant enhancements, enabling users to access a wider array of Bases with unique datasets for querying. This allows for even more dynamic and insightful reports.
Specifically, the latest update allows users to create reports with dynamic filters from the following Bases: Accumulators, Benefit, Claims, Drugs, Eligibility, Groups, Overrides, Pharmacy, PA Cases, and Tags.
Why This Feature Matters:
This feature democratizes data access within Judi, whether you’re looking to satisfy an ad hoc curiosity or schedule recurring reports. Each new data source, or base, improves users’ visibility into their own operations, enabling data-driven decision making.
#5 - Loading Incumbent PBM Claims Data
Judi is now able to support the loading of historical claims files via the front end by allowing users to configure, track processing events, QA erroneous data points, and – most importantly – load claims data from incumbents into our claims database. This helps fuel downstream processes like disruption reporting and continuation of therapy.
Why This Feature Matters:
Changing PBMs can be a daunting task, but Capital Rx’s implementation team has led thousands of plan sponsors through this process seamlessly.
One of the ways we make members’ transition to Capital Rx as smooth as possible is by leveraging historical claims files from incumbent PBMs. For example, Continuation of Therapy benefits rely on historical claims to identify members who need bridge fills of certain drugs and need to be notified to initiate PA requests.
With this feature, it’s possible to ingest these claims with appropriate oversight and quality assurance, enabling a successful go-live.
If you’re curious about our implementation process and what has made it so successful, click here to read our blog on the topic!
#6 - Medicare Prescription Payment Plan (M3P) Solution
Capital Rx created a standalone, turnkey, end-to-end M3P solution for health plans, payers, and PBMs that offer Medicare Part D. This solution covers billing and reporting, claims adjudication, cost sharing and tracking, program calculations, payment options, and the new pharmacy notifications necessary to meet CMS requirements – all in one system.
Why This Feature Matters:
Alignment with CMS is crucial for Medicare Part D plan sponsors. Each year brings new federal guidance and programming that challenge legacy PBMs’ infrastructure capabilities. Judi enables plans to be compliant and competitive when they participate in the M3P program.
#7 - A Modern Member Portal Experience
The Member Portal received a significant update and now has a new look and feel. Essentially, our team upgraded certain user interface (UI) components so they align with the common components used in Judi. This upgrade gives the member portal a modern design and empowers it with a technological architecture that will unlock self-service capabilities for white labeling of member-facing digital experiences for plan sponsors directly from Judi.
Why This Feature Matters:
Everybody knows how difficult it can be to navigate a clunky website. With a modern, optimized portal, users experience a clear, user-friendly interface that enables them to efficiently and painlessly find the resources they need.
#8 - Formulary Management Tool
Another new tool that went into development last year is Judi’s Formulary Management tool. By leveraging Consolidation Logic and using machine learning, this tool turns NDC-level files into general, Medi-Span-based rules to reduce management with new drugs rolling in. Furthermore, it uses inheritance logic to enable users to manage multiple formularies with ease.
This is the first formulary management tool integrated directly with an adjudication platform.
Why This Feature Matters:
Formulary management requires a delicate balance between clinical, legislative, and cost-effectiveness considerations. Formulary management is also a big data problem – there are up to 100,000 NDCs that need to be classified on a formulary at any given time. Hundreds of NDCs get published or otherwise change in subtle ways every single week. They may require assessment to properly place on each formulary according to its custom rules.
The Formulary Management tool aims to centralize these workflows and powers the creation of formulary data for claim adjudication, drastically reducing the work required to implement a new formulary.
#9 - Claims & Member Modules
Judi’s Claims module enables users to search for claims within an entire client and quickly surface high-level information for users looking for specific drugs, prescribers, and pharmacies associated with their members’ claims.
Diving into a member’s claims from directly within their profile is even more powerful. Users can quickly view a chronological list of claims associated with the member in Judi and take action to resolve access to care hiccups.
No matter if you are testing a prospective claim for a member experiencing a rejection at the point of sale or overriding that same reject with the click of a few buttons, Judi provides a snappy, effective, and specific member-level overrides from directly within the member’s list of claims to break barriers in access to medication.
Why This Feature Matters:
Healthcare is notoriously fraught with complexity and misdirection. Electronic infrastructure should not make it even harder for patients to navigate their care or for healthcare professionals to do their jobs.
That’s why navigating Judi is easy and intuitive, allowing users to troubleshoot, test, and understand claims processing results.
#10 - Member Experience Tools Module
Judi’s Member Experience Tools module enables our Client Services team to manage clients’ open enrollment sites and member portals. Users can customize the branding experience by choosing colors, uploading logos and background images, adding new client-specific content and URLs, and hiding pages that aren’t relevant to your client.
Why This Feature Matters:
Open enrollment is our first opportunity to introduce members to the toolkit they’ll have at their fingertips in the member portal and on the mobile app. The Member Experience Tools Module enables members to have the sleek, modern experience they expect that aligns with their plan sponsor’s wishes.
#11 – Payment Processing Integration
Judi leverages a payment processor for two products currently: Medicare Prescription Payment Plan (M3P) support and TPA eligibility for unions.
Medicare members who enroll in MP3 can make monthly payments instead of paying their standard cost share at the pharmacy. The idea is to make their expected out-of-pocket costs predictable and steady over the plan year. Employers who use union labor will be invoiced and can make payments to the unions’ self-funded health plans. Those payments will be reflected in Judi, allowing for end-to-end tracking and identification of delinquent employers. This integration enables visibility in Judi into payments made on behalf of our union clients for TPA Eligibility!
Why This Feature Matters:
By integrating with payment processors, Judi is able to provide users with a more complete picture of their healthcare journey.
#12 - Unified Claims Processing
If you’ve read our content or listened to our podcast, Astonishing Healthcare, then you’ve heard us mention “unified claims processing” and Judi Health™. What once seemed like a white whale is now a reality. Judi is capable of processing both medical and pharmacy claims, something no other enterprise health technology platform has achieved. Starting January 1, 2025, Judi began processing medical claims alongside pharmacy claims for Capital Rx employees and their dependents.
Why This Feature Matters:
As with many things in healthcare, the existing division between medical and pharmacy (along with vision and dental) claims processing would not exist if the system was designed in 2025. By housing both medical and pharmacy claim administration in Judi, Capital Rx is taking the first step toward harmonizing benefit offerings and empowering care management with visibility into every part of the member’s healthcare journey.
Learn More About the Benefits Modern Enterprise Health Technology Provides
Judi’s efficiency, scalability, and flexibility make it truly unique. Couple that with our Product team’s ingenuity and tireless work, and it’s easy to see why Judi is redefining what’s possible in healthcare.
If you’d like to learn more about Judi and how its capabilities can help Commercial, Medicare, and Medicaid plan sponsors, contact us today! You can also check out our podcast, Astonishing Healthcare, for further insights about Judi and the pharmacy benefits industry.