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Inside New PBA Biz, $106M Series C & Big Plans – The Health Care Blog

Jessica DaMassa

by JESSICA DAMASSA

What’s the larger information popping out of Capital Rx: that the next-gen PBM simply closed a $106 million greenback Sequence C? Or, that the well being tech startup’s enterprise mannequin has expanded considerably over the previous 18 months, from PBM-only to PBM-plus-PBA, which means that as an alternative of simply servicing the pharmacy advantages administration wants of employer teams instantly, that now they’re additionally including to their enterprise by promoting THEIR TECH to different carriers and well being programs to allow them to use it to administrate their advantages plans??

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Capital Rx’s CEO AJ Loiacono takes these questions in stride, lets us in on which “facet” of the enterprise fueled their 200% year-over-year development in 2021, and offers us the small print on that tech that his enterprise developed and why its standout in comparison with the inefficient infrastructure that presently exists to administrate and course of pharmacy claims.

The massive deal right here is that AJ and staff are tackling one of many greatest friction factors in the price of pharmacy advantages: the price to manage a plan. They scale back that value, and the “internet value” of each drug is lowered. AJ says its on this method that Capital Rx operates at one-seventh the price of his rivals, the “Massive Three PBMs” (CVS’s Caremark, Categorical Scripts, and UnitedHealth’s OptumRx) and saves its prospects a mean 27% on their prescription drug spend.

Now that Capital Rx has their slick enterprise software program, will the enterprise proceed to function a twin PBM-plus-PBA mannequin, or will they double-down on the PBA facet? AJ lets us know what’s subsequent and (spoiler alert) it feels like issues would possibly go in a stunning route. If Capital Rx’s software program is so efficient at doing all of the issues it takes to handle pharmacy claims — underwriting sequences, implementation administration and onboarding, communication, affected person portals, community administration, reimbursement networks, eligibility checks, and many others. – what stops Capital Rx from processing different kinds of healthcare claims? Is a step into the medical claims processing facet of the healthcare world on the roadmap? Tune in and discover out!

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