Justin Venneri
What’s missing from traditional PBA solutions?
To understand what pharmacy benefit administration (PBA) is about, it’s necessary to start with at least a basic understanding of what pharmacy benefit management (PBM) entails. This article won’t go into as much detail as What Is the Role of a Pharmacy Benefits Manager (PBM)?, but it’s worth quickly mentioning that a PBM solution is for groups like employers, labor unions, and federal and state governments and municipalities, among others, that need a third party to manage their pharmacy benefit program. In addition to contracting with everyone from drug manufacturers to mail order and retail pharmacies, PBMs handle all aspects of pharmacy benefit programs, including, but not limited to:
- Benefit design and plan setup
- Employee/member enrollment and customer service
- Claims processing administration
- The pharmacy network
- The formulary
- Prior authorization
- Drug utilization and clinical review
- Rebates and discounts
- Data integration/reporting
As Capital Rx CEO AJ Loiacono explained during an interview with WTF Health, hundreds of little, seemingly insignificant, mostly human capital-intensive tasks associated with each of the above add up quickly. AJ notes that “the system scaled with people on systems that are 20-30 years old.” As a result, the PBA solutions offered by traditional PBMs that are widely utilized by health plans and health systems throughout the U.S. are missing a modern touch.
What is a Pharmacy Benefit Administrator?
The distinction between PBMs and PBAs is relatively straightforward:
- PBMs process prescription drug claims on behalf of plan sponsors such as employers, government entities, or unions.
- PBA solutions provide prescription drug claim processing AND the enabling technology and services so others, including health plans and health systems, can set up and run pharmacy benefit programs on their own.
Is that it?
No. PBAs are not created equally. The 20-30-year-old systems mentioned above really do exist, and the inefficiencies, including those associated with spread pricing (MAC teams, monitoring unnecessary staff, etc.), are massive. Health plan executives, for example, want control over the pharmacy benefit program and to ensure a great member experience – not all PBA solutions are flexible and efficient enough to meet these needs. Enter JUDI®.
Who is JUDI®?
Glad you asked. If you’re responsible for administering a pharmacy benefit program but haven’t met JUDI, we need to set you up with a demo. JUDI, short for adjudication, helps Capital Rx deliver exceptional service to the millions of members that count on us for pharmacy benefits.
JUDI is a next-generation enterprise health platform (EHP) that unifies all PBM operations onto a single platform, automating those hundreds of little tasks to streamline operations and reduce costs. With JUDI's help, we operate at one-seventh to one-eighth the cost of our competition.
While we use JUDI to deliver PBM services to a wide range of organizations, JUDI can also be used by health plans and other entities so they can administer their pharmacy benefits with the same agility and efficiency we count on.
The Differentiator: Modern Technology Makes Life Easier, Especially for Medicare & Medicaid Plans
JUDI is designed to give plan sponsors and administrators all the tools and flexibility needed to do everything quickly and with relative ease. It’s also modular, which allows for customization to design the pharmacy benefit that suits your needs. Because JUDI is cloud-based and has an open API architecture, scalability and interoperability challenges are non-issues. With a thoughtfully constructed EHP, everything from implementation to edits at the plan, group, and member levels is easier.
JUDI helps our clients – including those focused on Medicare and Medicaid populations - understand what’s happening with their pharmacy programs in real-time. The level of transparency and visibility allows health plans, for example, to better project costs. Star Ratings and the risk adjustment factor are crucial for Medicare Advantage plans, and the first signal that something is wrong with a member may be a prescription. Having this information at your fingertips or flagged for you is what JUDI is great at.
- Legacy EHPs were not designed with the latest government requirements in mind and often must shoehorn their functionality to meet regulatory standards. This can result in errors, fines, and a suboptimal patient experience. But with JUDI, these frustrations are left behind. JUDI was built following the enactment of Medicare Part D and easily handles Medicare and Medicaid claims processing requirements, so there's no need to worry about bending outdated systems to meet regulatory standards.
Providers, including hospitals, health systems, and long-term care or senior living operators, may own pharmacy assets and have the clinical expertise necessary to deal with members directly. JUDI is a perfect partner for anyone looking for more direct control over pharmacy program costs via utilization management, formulary, or other clinical programs.
It’s Safe and Easy to Switch
Capital Rx clients typically see double-digit year-over-year cost savings leveraging JUDI and our Single-Ledger Model™. The implementation process is smooth and efficient, and having an aligned partner by your side results in financial flexibility and predictability. The collective benefits create a high-end member experience and allow PBA customers to be more competitive. Don’t let comfort, short-term promises, or anything else limit the potential to have flexible, next-generation technology at your fingertips.
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