Capital Rx, the full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA) advancing the nation’s healthcare infrastructure to improve drug price visibility and patient outcomes, has officially secured a U.S. Patent for its novel data tagging system used in JUDI®, the company’s proprietary enterprise health platform. According to certain reports, the stated tagging technology makes it possible for users to configure custom rule sets, without mandating the use of programming at any point whatsoever, to conceive the desired outcome. By doing so, such a setup effectively eliminates many technological difficulties users often encounter in legacy claims processing systems. Talk about the whole value proposition on a slightly deeper level, we begin from its promise to enable a prior authorization (PA) bypass. This is especially applicable for situations where a continuous glucose monitor is prescribed for a patient with a history of insulin use, of when there’s a specific diagnosis code. It is also applicable when a particular physician writes the prescription (i.e., Gold Carding). Next up, we must dig into how the system can inform PA process and allow for determinations regarding whether the claim is an administrative denial (i.e., not covered by a plan) or if it should go through the full review. Joining the same would be a feature which presents reasons for approval or rejection on the outcome of a claim. A mechanism of this sort is, by and large, meant to enable faster research and better communication with members, providers, and pharmacies.
“Smart tags and overrides, as we refer to them, are among our favorite JUDI features because they allow our teams to be incredibly nimble and responsive to our clients’ needs,” said A.J. Loiacono, Co-Founder & CEO of Capital Rx. “There’s no need for ‘ruleset prioritization’ or additional hours of overhead cost associated with programming to make simple, intuitive changes in minutes. With JUDI, our clients can respond appropriately to anything from new regulatory guidance to a natural disaster or be creative around meeting members’ unique needs.”
Hold on, we still have a couple of bits left to unpack, considering we still haven’t acknowledged how Capital Rx’s now-patented solution even lets you control utilization, as well as prevent fraud, waste, and abuse. This it does through multi-product “refill too soon” overrides for medications like opioids or glucagon-like peptide-1s (GLP-1s). Rounding up highlights would be a facility to set a zero-dollar cost share for test strips when a patient has a history of insulin use.
Having referred to its tagging system, we must also shed some light upon Capital Rx’s JUDI platform, which is purpose-built to redefine the administration of Medicare, Medicaid, and Commercial pharmacy programs. Interestingly, while it was originally built to just consolidate all pharmacy benefit-related workflows in one system and improve costs and service levels in the commercial market, the platform’s adaptability and modular framework would allow it to expand dramatically, and therefore, eventually serve Medicare and Medicaid plans. Not just that, it also prepared the solution to facilitate rapid development and deployment of new products to meet clients’ needs.
As for Capital Rx, founded in 2017, the company’s excellence in what it does can be understood once you consider it has a 100% implementation satisfaction rating, as well as a 99.5% client retention rate. Apart from that, Capital Rx also boasts >90 climate net promoter score, along with >87 member net promoter score.
“We are committed to investing in and upgrading JUDI’s capabilities and the workflows that create efficiencies in the deployment and management of pharmacy benefit programs,” said Ryan Kelly, Co-Founder and Chief Technology Officer. “The fact that many legacy systems rely on hardcoded data structures and are difficult and time-consuming to alter is something we have and will continue to address through innovation.”