GHAPPcast: Payer Tutorial

September 2025

In this podcast, pharmacist Jeffrey Dunn and Dr. Ed Pezalla boil down how U.S. managed care really works—covering Medicare, Medicaid, and commercial insurance, the difference between self-insured vs. fully insured risk, and how PBMs and health plans split responsibilities across the pharmacy vs. medical benefit. You’ll learn why formularies, prior authorizations, step therapy, and utilization management exist, how to navigate them, and what to check on the back of the insurance card before you start a PA. The conversation offers a practical playbook for clinics: map your region’s top payers, gather their PA criteria and forms, document the right clinical data up front (the #1 cause of denials is missing information), and build working relationships with payer teams. They also touch on the impact of specialty drug costs, biosimilars, and the growing role of technology/AI in streamlining approvals—all aimed at aligning outcomes, patient experience, and cost.