Capital Rx
It was such a joy to see everyone in New York City at One World Trade Center for our annual Partner Summit! Capital Rx team members, industry experts, current and prospective clients, and channel partners gathered for this exclusive event to discuss the most pressing issues in benefit administration and healthcare, and the exchange of ideas about how to improve the system and put the “care” back in healthcare was extraordinary.
Here are the highlights from our second annual Partner Summit.
Day 1: Regulatory Complexity, GLP-1s, Pharma-PBM Contracting, and the Future of Benefit Administration
A host of experts joined us on March 24th to cover some of the most pressing issues facing employer plan sponsors and health plans alike: regulatory changes in Washington D.C., the financial implications of GLP-1s, what plan fiduciaries must do to stay compliant and cost-conscious amidst lawsuits and scrutiny, and how the introduction of Judi Health™ presents a new path forward for healthcare: one that is more aligned, cost-effective, and prepared to meet plan sponsors’ evolving needs. We ended the night discussing our partnership with New York City Football Club and our focus on engaging with and benefiting the local NYC community.
Regulatory Round-Up: Navigating Fiduciary Responsibilities, Data, Compliance, and Cost
Capital Rx’s General Counsel and Chief Compliance Officer, Lloyd Fiorini, discussed employer plan sponsors’ fiduciary obligations and health policy priorities with Jonathan Levitt, Esq. (Trial Attorney & Co-Founding Partner, Frier Levitt) and Nick Welle (Partner & Chair, Health Benefits Practice, Foley & Lardner LLP).
- Jonathan explained the issue clearly: plan sponsors were not scrutinizing their pharmacy benefit plans. Instead, everyone relied on third parties’ advice and essentially allowed costs to run away from them and misaligned traditional PBM business practices to become commonplace.
- “What do people have to do as a fiduciary?” A high level, Nick explained that putting a reasonable process in place to manage and monitor the benefit and ensure that the services provided to the plan by contracted vendors meets expectations and benefits plan members; “it’s about doing and documenting homework.” (For more, check out AH052, with Nick Welle).
- To avoid becoming the next Johnson & Johnson, Wells Fargo, or JPMorgan, plan fiduciaries must ensure everything is optimized in the interest of the plan – from rebates to the formulary and beyond. Removing gag clauses from contracts should allow for data access, and setting up a reasonable process involves establishing a benefits committee, holding quarterly meetings, and having a robust RFP process (involving several bidders, including new entrants, unconflicted consultants, etc.). A good place to start is the list of drugs mentioned in the lawsuits – i.e., compare what the plan pays to publicly available prices.
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- AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
- AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?
Beyond the RFP process, monitoring performance (vs. benchmarks or SLAs) to ensure contractual obligations are met and obtaining fee/compensation disclosures shows the effort needed to meet the new requirements.
- The Trump administration is pushing for public disclosure of prescription drug rates – including historic paid rates, which could lead to a normalization of rates and “open up a box of what rates could look like,” said Nick.
- States are aggressively pushing for PBM reform, but PBMs continue to claim ERISA exemption. The potential remains for de-linking and other reform initiatives to eventually pass at the federal level.
The Intersection of Pharmacy and Evidence-Based Obesity Care
It’s no secret that glucagon-like peptide-1 (GLP-1) utilization is a primary concern for employer plan sponsors, health plans, and other payers. With how expensive these drugs are and how wide their potential use seems to be, everyone is understandably focused on how to deliver the best quality care for their members while being cognizant of their budget.
Sara Izadi, PharmD, Chief Clinical Officer at Capital Rx, and Michael Glickman, MD, Founder and CEO of Revolution Medicine, Health & Fitness, broke down the challenges and some of the levers that plan sponsors can pull to help manage obesity within their populations.
- Dr. Glickman said patients are doing their homework and coming into the practice with a “GLP-1 agenda; everyone has heard and focuses on the success stories; patients are willing to carve the $500/month out of their family budget to pay for them.”
- As an insurance-first practice, the complexity of managing patients has grown considerably – there’s an entire administrative team handling prior authorizations, appeals, peer-to-peer reviews, etc.
- Gold carding is an appealing way to streamline care, but Dr. Glickman said primary care physicians are often able to prescribe medication to this patient population, and it shouldn’t be more challenging for them (i.e., there must be a way to remove the barriers).
- The best way employers can address the rising cost of obesity care and improve outcomes is to involve specialists, but measuring success is a challenge, said Sara, because the average employee lasts fewer than 4 years at a company, and Dr. Glickman noted that “the horizon to measure outcomes is decades; we’re preventing someone from developing hypertension, fatty liver, kidney disease, or cancer and reducing hospitalizations – but these outcomes are going to happen.”
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A Window into What’s New with Pharma – PBM Contracting
GLP-1s came back into the discussion as RSM’s Tom Evegan and Capital Rx’s Bryan Birch broke down the need for parity of some sort, as the U.S. continues to pay substantially more than the rest of the world for drugs. Additionally, they covered key issues around the Inflation Reduction Act (IRA) price negotiations, and then dove into brand positioning, rebates, and biosimilars, and finished up with a discussion about 340B developments and health policy/macro issues impacting drug manufacturers.
- With the government identifying over 3 million patients on GLP-1s, they’ve been named the #1 drug to negotiate in 2028. Manufacturers are negotiating prices for products they’ve never had to, said Tom, which means payers are negotiating more, too; “It’s a slippery slope.”
- The gross-to-net bubble, with all value put in, is estimated to be ~$330 billion, and total drug spend in the U.S. stands at ~$800 billion. That is an immense amount of money – rebates, copay assistance, discounts, patient assistance programs, etc. – flowing through the healthcare system for pharmaceuticals to the benefit of traditional middlemen.
- Using Omeprazole and esomeprazole (Nexium) for reference, Bryan highlighted the increases seen for brand rebates and how that dynamic impacts a plan’s decision-making. For Humira, Stelara, and others, it appears as though a race to the bottom is imminent.
- Tom highlighted public data showing that Johnson & Johnson represents ~10% of the 340B market and explained the program’s explosive growth, why drug manufacturers are challenging it and installing their own rebate programs, etc. However, as Tom and Bryan expressed, it’s only a matter of time before a holistic solution is found and everyone works together.
- In terms of government policy and the new administration, Bryan and Tom discussed the fact that innovation is going to be cut, with NIH grants down overall. Companies that signed up for innovative medicine and should have been funded don’t know when they’ll receive those funds. On top of that, CMS is losing key people who helped design programs, and there is a general shift in personnel across multiple agencies – including the FDA, CMS, and NIH.
Judi Health™ – The Pursuit of Unified Claims Processing™ and Leading to Value-Based Healthcare
If we designed the American healthcare system in 2025, we certainly wouldn’t have all the silos and disconnected systems that currently exist. However, that’s the current issue, and as Capital Rx Co-Founder & CEO AJ Loiacono put it, “The invisible line of self-interest and everyone negotiating in their own ways” got us here. AJ was joined by Capital Rx’s Chief Innovation and Medical Officer, Dr. Sunil Budhrani, for a walk through the future state, where claim adjudication and workflows across pharmacy, medical, and other programs are consolidated on a single, open, scalable platform (Judi®): Judi Health™.
- AJ estimates that the U.S. healthcare system likely contains more than $1 trillion of administrative waste attributable to legacy infrastructure and redundant processes. That’s why we need a single source of truth where everyone can see all the workflows in real time.
- With Judi Health, Capital Rx has introduced Unified Claims Processing™, finally bringing together pharmacy and medical claims processing (with an eye on dental and vision claims in the future). Similar to how Microsoft overtook Borland and displaced Word Perfect, “When you have four products tied together, nobody can beat you,” said AJ.
- Starting in January 2025, Capital Rx moved its team to Judi Health. Although it’s still very early, we’re seeing cost savings overall for our population of ~1,100 members, and the initial member experience stats are amazing. In short, Judi Health presents a scalable, cost-effective, and dependable future for healthcare that eliminates administrative waste and redundancies.
- Sunil explained how everything can work if you “empower the provider-patient relationship;” because the stars are realigning. “Patients have had it, providers have had it; we can help anyone behave like a health plan and operate more efficiently.”
A Goal for Good: Capital Rx and NYCFC’s Community-Focused Partnership
In February 2024, Capital Rx and the New York City Football Club entered a partnership focused on benefiting the local NYC community. In the first 12 months of their partnership, our organizations collaborated on various initiatives, including volunteer efforts in the community, mentoring events, and much more. Michael Passanante, SVP of Marketing and Communications, and Brad Sims, CEO of NYCFC, led a dinner session together, breaking down this unique partnership, what we accomplished, and what’s next.
Day 2 - Next-Generation Healthcare – AI Initiatives, Judi® Features, Client Experiences, and Never Move Again™
On March 25, we continued important conversations about the future of healthcare: our unbundled pharmacy benefits solution, Never Move Again™, Judi features that aid plan sponsors, thinking about value outside of the traditional spreadsheet, and how AI can improve healthcare.
Plus, we had a panel of current clients discuss their experiences transitioning to Capital Rx, and they shared some of the results!
The Nuances of Unbundling Pharmacy Benefits - Never Move Again™
We led off the day with a deep dive into Capital Rx’s unbundled pharmacy benefits solution, Never Move Again™, which reinvents how we look at the process of administering a pharmacy benefit, creates flexibility and cost advantage, and enables larger employers to serve their members in a way that meets their needs.
Furthermore, adopting Never Move Again™ provides a unique opportunity to be ahead of the curve. The tech aspect of this solution is critical—both in terms of meeting plan sponsors’ compliance needs and members’ expectations and driving the healthcare agenda toward a more aligned, cost-effective, and plan-focused future.
Tags and Overrides — How this Patented Judi® Feature is Aiding Plan Sponsors Daily
One of Judi’s most popular and intuitive features, Tags and Overrides (which has a U.S. Utility patent), represents a core part of Capital Rx’s approach to pharmacy benefit administration: asking, “What is the market looking for?” or, “What must we do quickly for our clients?” The answer to that is simple: deliver for our clients and their members – not just in terms of our solutions but also in the tools plan sponsors have at their disposal.
Tags and Overrides serve that function. This “if, then” feature is helpful and adaptable, enabling users to exclusively configure it, program stamp for reporting, identify how many claims are processing against it, and handle messaging and POS rejects.
Furthermore, users can create the most complex criteria set to effectuate an outcome, and it’s supported in the Tags and Overrides feature. A unique ID is generated that ties back to a specific claim in Judi. This makes reporting even easier.
How to Think About Value Outside of the Spreadsheet
The focus of a traditional pharmacy benefit procurement process has historically been on unit costs and the number of units. As Kristin Begley, PharmD, Capital Rx’s Chief Commercial Officer, and Mike Miele, SVP of Insured Services – “the pharmacist and the actuary” – explained during this session, people don’t measure drug mix well, and aren’t accountable for forecasts. Thus, the traditional view is limited and does not capture the whole pharmacy cost picture. In fact, when you overweight unit costs, we think you’re only assessing about 30% - 33% of future costs.
Another 20% of baseline cost differences include rebate withholding and other ancillary fees, the full pass-through of rebate value, coupon fees in percentage versus flat fees, and ancillary program fees (as a side note, plan fiduciaries should remember to ask for invoices!). Meanwhile, clinical programs impact the other 50% of future costs! So, “drug mix matters” a lot, and the contract definitions that dictate the flow of pharmaceutical revenue to the plan are of the utmost importance to understand.
Client Experience Moving to a Non-Traditional PBM
We know that implementing a new benefits partner and going through the PBM procurement process can be daunting.
As Melanie Huff, SPHR (Vice President, Total Rewards, HR Operations & Technology, HNTB), Jeannine Chiappini (Vice President, Benefits Consulting Practice Leader, Borislow Insurance), Maria Scheeler (Executive Director/Administrator, Teamsters Health & Welfare and Pension Funds of Philadelphia and Vicinity), and Lisa Trumble, MBA ACOs (President & CEO, SoNE HEALTH) pointed out, it's difficult to harness the courage to take action and change a mindset, especially when that decision will impact thousands of member lives.
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That’s why the panel stressed the importance of making the change on behalf of the group and helping everyone adapt to that change. After all, the results speak for themselves.
As Jeannine put it, “We are two years into the contract now, and we are at the point in our annual cycle where consultants are meeting with the schools and doing renewals. We are forecasting negative pharmacy trend for the schools. And we have a $30 PMPM savings versus two years ago.”
Similarly, Maria mentioned that, during her RFP, AJ and the team did a “reprice” of a year’s worth of claims that, alone, showed $3 million in savings for the plan.
Best of all, each leader on the panel had a specific thing they loved about Capital Rx from a client perspective:
- Melanie: The team's responsiveness to her needs.
- Jeannine: Capital Rx’s implementation was 100% seamless, and the organization has “the highest regard for service that I’ve seen anywhere.”
- Lisa: Service. There are no complaints. We heard, “This was the first time my prescription was lower than my copay!” And the conversion was “seamless.”
- Maria: “I don’t receive phone calls – that means members are getting what they need.”
AI Initiatives – How AI Can Improve Healthcare, for Real
We ended day two on a hot-button topic: AI in healthcare. Specifically, how can AI initiatives improve healthcare for everyone in the healthcare ecosystem?
Sara Ganz (Chief of Staff at Capital Rx) moderated a discussion between Ryan Kelly (Chief Technology Officer, Capital Rx) and Steve Violette, PharmD, MBA (Chief Operating Officer, One Health Link), and they highlighted several specific use cases where AI can be leveraged to create greater efficiency by speeding up the processing of paperwork or helping consumers (e.g., pill identification and member navigation), for example.
As wild as it sounds, the facsimile is still widely used for document transfer in healthcare in 2025. This is a perfect area where AI, layered on top of the intake process, can improve workflows and enable people to get the information in the fax in a structured manner.
Surfacing information is a key area where AI can create efficiency, said Ryan. Right now, people desire to have information and answers in real time. AI can make it easier and quicker to surface the necessary information to drive faster results.
Additionally, one of the most exciting AI developments is AI agents and the potential for agentic AI to aid in the call center. As Steve explained, something as simple as ambulatory aid took his CEO double-digit hours to set up for a personal matter, requiring him to connect information from various systems to tie more complicated tasks together. “And this is someone who has been in healthcare for 30 years, knew DME providers, etc.!” In that circumstance, leveraging an AI agent could take a strenuous process and make it much more efficient.
But as Ryan also pointed out, AI isn’t magic. There are many unsuitable activities, and it’s vital to identify which areas to leverage and then deploy them with a thoughtful strategy.
Learn More About Capital Rx’s Solutions and Judi!
If you want to dive further into the topics we discussed at our 2025 Partner Summit, check out our Insights page for all the linked content and much, much more! We have a ton of Pharmacy Benefits 101 content, press releases, posters, and more covering everything from rebates to formulary management and specialty drugs available.
Additionally, be sure to listen to the Astonishing Healthcare podcast, where we invite colleagues and guests from around the healthcare ecosystem to discuss timely topics weekly.
Lastly, make sure you follow us on LinkedIn and subscribe to our newsletter for the latest pharmacy benefits updates, Capital Rx news, and expert perspectives.