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Justin Venneri
Capital Rx’s Jason Barretto, Vice President of Government Programs, explains how JUDI® is designed to handle new requirements with relative ease in this final installment of our 4-part interview providing a “Behind the Scenes” look at how Capital Rx delivers on providing clients with a truly differentiated pharmacy benefit administration (PBA) solution.
This Q&A, which is, for all intents and purposes, a case study in interview format, is lightly edited for length and clarity.
For the New York State Medicaid fee-for-service point-of-sale Reject 831 example, Capital Rx was the only PBM able to immediately address the requirement, right? Can you explain why and how JUDI® allowed us to be nimble and create a solution?
Yes. JUDI is built with features that are innate within it and flexible. As New York was carving out Medicaid managed care to fee-for-service, a requirement came up to have PBMs fire a reject code at the point of sale (POS), notifying the pharmacy that the prescription they tried to run should be submitted to the fee-for-service PBM.
During the discussions with the Department of Health, the PBMs that represented the client base in NY took significant issue with this because it would require a major overhaul of how the claims engine would trigger the order of edits at POS. When you have a specific global order of operations and an inflexible system, and then something like this happens, you run into trouble.
So, this customization request took the big PBMs by surprise, and it got to the point where they wanted the Department of Health to essentially walk back that expectation. They provided a unified opposition as to why it wasn’t in the best interest of the state, clients, and members. I think they spent countless hours on calls trying to get them to walk it back. Capital Rx was the only PBM that was able to say, “We can do this, no problem.”
So, we stood down from the rest of the dialogue because we didn’t oppose the state’s requirement. We thought it made sense, wanted to support it, accepted it as designed, and made recommendations on how to further reinforce POS messaging to drive the best possible outcomes for the state and plan members.
Eventually, the PBMs were able to accommodate the requirement, but there was a lot of dragging of feet and trying to convince the state it was a bad move. All of that wasn’t necessary. We were the only ones ready to turn on the primary edit any time they wanted.
And why is that?
Tech enablement. That’s what JUDI allows. It’s what JUDI was built to do. We could enable an override to the standard order of operations for POS edits and allow the reject 831 with custom messaging that the state wanted to fire vs. all the other edits. When I asked the team if we could do it, the response was, “That’s a pretty simple deliverable.”
Can you give another example of how JUDI's innovation has enabled something that helps health plans service their members?
Sure. Within JUDI, in addition to the messaging that pharmacists see, we built plain language messaging that call center representatives can see to understand what’s happening at the POS to help them support and service the pharmacists and members. This is an efficiency mechanism that helps with accuracy as well. We can quickly help explain why the pharmacist is getting the edit and message and work with them to sort out how to bypass the messaging or do what needs to be done (e.g., submit a prior authorization request). It’s all built into the system and at our team’s fingertips.
Related Government Programs Content
Capital Rx’s Government Programs: Behind the Scenes with Jason Barretto
Partnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management
Government Programs: The True Meaning of Customization
Contact us if you’d like to learn more about Capital Rx and what JUDI can do for your pharmacy benefit program and beneficiaries.