How RBP Plans Can Easily Contract With All Providers

August 20th, 2018
By Bill Rusteberg
Through an innovative plan design, Reference Based Pricing (RBP) plans seeking to contract with local providers can do so quite easily.  It’s turning lemons into lemonade and it’s called an APO (All Provider Organization).

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Is Low Bid Always The Best Bid?

August 19th, 2018

The science of how to compete against “low bid” is a discipline learned by losing. Over time a seasoned salesman will learn how to beat the “low bid” and win more than he loses.(How To Win Against A Competitor’s Low-Ball Price Bid – Forbes)…………….In the article that follows the “high bidder” who lost to the “low bidder” is protesting. Is the $700,000,000 savings really true……………….? Common sense dictates otherwise.

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Dirtiest Industry Secrets Exposed By Retired Insurance Agent

August 19th, 2018

This anonymous agent reveals the dirtiest secrets of his profession, and the rules for building your personal safety net

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Telemedicine + Teachers = A+ Combo?

August 19th, 2018
Niche marketing is a smarter way to quicker sales………………….

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How Much Did You Pay For Your Banana?

August 18th, 2018

Imagine a banana in a supermarket.  It costs $1 for those paying with Visa, $3 for those paying with MasterCard, and $32 for those paying with cash.  You can’t sign up for Visa until you’re 65, and you can only get a MasterCard if you have a nice employer or a decent income.  Worse, customers have no idea that such price discrepancy exists.  They don’t even know how much they’ll pay for the banana until long after they’ve eaten it…………………

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Friends With Benefits Episode #9

August 17th, 2018

Jeff Bernhard and David Contorno interview  William Rusteberg on Reference Based Pricing

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Connecting Consumers With High Performance Medical Care

August 17th, 2018

It’s a fact that a huge variation exists in surgical quality by hospital. A hospital that has great outcomes in one type of surgery (such as orthopedics) may have poor outcomes for other surgery types (such as cardiac surgery or women’s health). Based on this, BridgeHealth created a program that connects members with high performance surgical facilities for their specific surgery type.

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Competitive Health Named to the 2018 Inc. 5000 List

August 17th, 2018

August 15, 2018 by Alex Mulvenna

IRVINE, Calif–August 15, 2018–Competitive Health, Inc., a leader and innovator in network and ancillary product solutions (CHI), today announced that it has been named to the Inc. 5000 list.

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Quality Is Not A Constant In PPO Networks

August 16th, 2018

There are quality providers and poor quality providers. Why would you choose the later?

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Beware of Health Care Consultants’ Partnerships

August 15th, 2018

This article exposes a common practice in our industry and should be read by every CEO. Brokers and consultants earning undisclosed commissions through recommendations they make happens all the time. I see it and expose it but CEO’s don’t. Try showing some of them the evidence and see the reaction. 

Recently I was tasked in reviewing a 2,500 employee school district in Texas. Disclosed compensation to the Agent of Record was $128,000. Actual compensation was $614,000 shared by two brokers one of which the district never met or knew. What did the district do? They fired the brokers and hired a local broker to earn the $614,000.  –  Bill Rusteberg

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Blue Cross Hit With Flurry of ERISA Lawsuits – Again

August 13th, 2018

When are plan sponsors going to wake up? Hidden fees driving up health care costs are more common than you would think. But its true. We could name dozens of lawsuits filed over recent years exposing practices that would make your toenails curl up. Here is one example:Weslaco ISD vs Aetna Yet many plan sponsors look the other way and continue to fund the conspiracy…………………….

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Cutting Out The Middle Man

August 12th, 2018

Have you ever wondered why healthcare spending is so high? We did. So we decided to peel back all the layers in the system and really look at where all the money was going. We were surprised by what we found……………………..

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The Attack of The Rebates (COMMISSIONS)

August 11th, 2018

Health and Human Services Secretary Alex Azar has said Americans “do not have a real market for prescription drugs” because drug middlemen and insurers get a wide range of hidden rebates (COMMISSIONS) from drugmakers, but those savings may not be passed on to consumers or Medicare.

Editor’s Note: Lets not pretend any more. “Rebates” are simply “Commissions” paid to third party intermediaries to push drugs. Dressing up the English language like calling welfare “subsidies” and crippled “handicapped”, and queer “gay” may give a softer touch, but is it really necessary? The meaning is the same isn’t it?

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Defending The ACA Versus Enforcing The ACA In Texas v. United States

August 9th, 2018

A potential upcoming preliminary injunction could block enforcement of the entire ACA or, alternatively, of the individual mandate, guaranteed issue, community rating, and preexisting condition exclusion ban provisions of the ACA………………….

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Are Employers Ready to Shake Up Health Care?

August 9th, 2018

Frustration with the US health care system is mounting. There’s a disconnect between what we spend and what we get in terms of high-quality outcomes and a good patient experience. Employers have the power to change that………………………….

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Schuessler Highlighted in Employee Benefit Adviser

August 8th, 2018

Employee Benefit Adviser has just published an article this week listing the top social media users among insurance advisers across the United States. The usual suspects were listed, like Carl Schuessler the famed inventor of the ever so popular Schuessler Stick……………………………….

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Whistleblower Will Receive $17.2 Million From Overbilling Case

August 6th, 2018

A San Diego whistleblower will receive $17.2 million with the settlement of a 7-year-old false claims lawsuit against Prime Health Care regarding overbilling for Medicare services at 14 California hospitals.

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Guess Who Will Pay For Prime Healthcare Settlement?

August 6th, 2018

Passing along losses to consumers is one pen stroke away……………Will Prime Healthcare renegotiate their managed care contracts?

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David “Nostradamus” Contorno Reveals Amazing Prediction

August 5th, 2018

David “Nosradamos” Contorno

I’ve hesitated to predict this publicly…but I am ready to now…………………….(Drum roll please)

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Specializing in Specialty Drugs: A New Middleman Steps In

August 5th, 2018

Companies that negotiate for better prices on specialty drugs without the incentive of discounts and rebates…………………………..

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Trump Administration Exploring Idea of Importation of Drugs

August 4th, 2018

It came as something of a surprise when Health and Human Services Secretary Alex Azar announced that the administration was exploring the importation of prescription drugs to fight high domestic prices……………………

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CEO Finally Realizes Health Care Was His Problem

August 3rd, 2018

“If you employ a workforce and offer benefits, your business IS a healthcare business” – Jim Immelt

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San Antonio Firm Saves on Specialty Drugs

August 3rd, 2018

San Antonio firm provides alternative source for specialty drugs with significant savings………

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Rx – Where Does All The Money Go?

August 2nd, 2018

“[In] 2016, total US expenditures on pharmaceutical drugs, including the gross profits of all the intermediaries, were $480 billion … Two-thirds of this total ($323 billion) was captured by drug manufacturers in the form of net revenues. The remaining third ($157 billion) was retained as gross profits in the supply chain.

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TRS ActiveCare Announces Benefit Changes, Rate Increase 2018-2019

August 2nd, 2018

The TRS Board of Trustees has adopted medical and pharmacy benefit changes to reduce a projected premium increase to 5.7 percent, instead of 7.2 percent. The main benefit changes were to add new freestanding emergency room (ER) copays and adjust specialist copays, deductibles and maximum out-of-pocket amounts.

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Two-Sided Transactions – How Will Supreme Court Decision Affect PPO’s?

August 1st, 2018

On June 25, the US Supreme Court issued a 5–4 opinion in a case that may have significant implications for health care……………….The case of the two-sided transaction………………

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Association Health Plan Regulation Face Challenges

August 1st, 2018

“The DOL acknowledged that AHPs will be MEWAs and that states will retain their existing authority related to MEWA regulation and enforcement….

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Trump Delivers On Promise of More Affordable Health Insurance Options

August 1st, 2018

Article Referred By Dan Meyland – Allied National

HHS announcement below – 12 month STM Contracts renewable for 36 months (details below)

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Medical Claims “Killing” Webb County Self-Funded Health Plan

July 31st, 2018

The following article appeared in the Laredo Morning Times almost a year ago. What has the county done since to address rising health care costs? From our vantage point, essentially nothing…………………

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Only One Election Away…………………

July 30th, 2018

Bernie & The Elephant In The Room

“If every major country on earth can guarantee health care to all, and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States cannot do the same” – Bernie

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Centivo – A New Type of Health Plan

July 30th, 2018

Centivo, a New Type of Health Plan, Raises $34 Million in Series A Funding

Next Generation Self-Funded Health Plan Launched to Help Employers Deliver Affordable, Sustainable Healthcare for Their Employees.

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CMS Picks Fight With Powerful Hospitals?

July 27th, 2018

   THE COST IS TO DAMN HIGH!

The Centers for Medicare & Medicaid Services proposed significant cuts to the payment hospitals receive for care they provide to Medicare patients…………………

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Trump Officials Scoff at ‘Medicare for All’ Drive

July 27th, 2018

Medicare is running out of other people’s money, and those other people happen to be our children……

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50 Rural Hospital CEO’s To Know

July 27th, 2018

The CEOs featured on this list have overcome significant challenges operating rural community and critical access hospitals to lead sustainable and thriving organizations……………….

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.006 Cents On The Dollar Removes Medical Debt

July 26th, 2018

Independent primary care providers donate over $10,000 to buy $1,474,987.25 in unpaid medical bills………………………….

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Health Care Maverick Hits The Airwaves

July 25th, 2018

Hello again everyone. I’m writing you all once again, but this time to share two radio appearances I made last weekend.

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ScriptSourcing: Ensuring Rx Access & Affordability

July 25th, 2018

Founded by CEO Gary Becker, a health insurance and risk management consultant for more than 30 years, ScriptSourcing works with employers to rein in the costs of Rx spending through a coordinated, seamless approach involving several key programs.

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The Cost of Convenience

July 24th, 2018

ppoo

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Some Texas School Districts Want Out of TRS ActiveCare

July 23rd, 2018

Since 2015, some El Paso school district employees and lawmakers have been asking the state to let them leave the program…………………………….

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The Health Care Payers That No One Has Ever Heard Of

July 20th, 2018

Go Away, I’ve Never Heard of Them!

What must we do when a patient presents an insurance card that lists no insurance company and no PPO network? We must reject them, the bible says so!

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School Teachers Are The Ones Paying For Health Care, Not Their Employer

July 20th, 2018

Teachers pay 100% of their health insurance, not their employers. How? Lower pay so the difference can be generously paid by the employer……………………………

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Do Hospitals Lose Money on Medicare?

July 19th, 2018
Do hospitals lose money on Medicare? Google that and see all the articles that claim so and the few that say not. So what is the truth? Here is one expert’s view (which we share by the way)………….

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Doctors & Hospitals Sue Patients

July 19th, 2018

Beware what you put on social media – you may be sued………………..

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Insurance Consultant Sentenced

July 18th, 2018

     William O. Haff

After more than three years in limbo, William O. Haff has finally learned his fate.

Haff has plead guilty to accepting bribes to steer his consulting clients to broker The Mullen Group. Sam Mullen of The Mullen Group has been given a prison sentence related to the scheme.

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U.S. To Make More Drugs Easily Available, Cutting Role Docs Play

July 18th, 2018

Americans may soon be able to get cholesterol-lowering medications and other widely used prescription drugs without seeing a doctor, a first step in what could amount to sweeping changes to how patients access treatments for chronic conditions…………….

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GROWDEN v. GOOD SHEPHERD HEALTH SYSTEM

July 18th, 2018

$25,308 Emergency Room Visit

Hospital sued for egregious pricing…………hospital responds by waiving all charges………Judge dismisses lawsuit…………Plaintiff appeals and wants to continue the lawsuit………….Appellate court agrees……..lawsuit continues……………..What is reasonable value of the treatment? Stay tuned……..

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HealthSmart® Launches SmartDecision™ Reference Based Pricing Solution

July 18th, 2018

The Reference Based Pricing movement is unstoppable. More vendors are entering the arena, moving away from managed care networks. HealthSmart is the newest entrant…………….

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Insurance Consultant Faces Sentencing

July 16th, 2018

William O. Haff

After more than three years in limbo, William O. Haff will learn his fate today before a Federal Judge.

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HHC Group

July 16th, 2018

As part of its broad suite of cost-containment services, HHC Group provides Medical Necessity (Bill) Reviews (MNRs) for Group Health, Auto and Workers Comp claims. Our Board certified physician specialists review medical records and billed codes to ascertain whether the services and supplies are appropriate and essential. They base their determinations on CMS and other nationally published and recognized guidelines (FDA, AMA, MCG, Cancer Institute, etc.). We do MNRs for all types of claims; prospective, post-service/prepayment and post-payment.

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Hospitals Don’t Mind Being Overpaid So They Are Not Complaining

July 16th, 2018

David Belk is at it again. Someone please send David a Schuessler Stick ( The Schuessler Stick™)

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In Health Care The Law of Supply & Demand Doesn’t Exist

July 15th, 2018

The law of supply and demand doesn’t apply to health care. Lower demand means higher cost.

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I Will Show You How To Cut Your Rx Costs by 50%

July 14th, 2018
I’m talking perception vs. reality on our next Expert Session, 7/17. The Pharma industry lobbies for big box PBMs and if you think you’re in good hands, consider this your wake up call…………….

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The Ever Outrageous Outlier

July 13th, 2018

This one (lawsuit) appears to be all about outlier provisions, and what happens when a really high dollar claim hits a plan………………………………..

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Paychex Now a ‘Top 20’ Insurance Agency in the U.S.

July 13th, 2018

Paychex ranks as one of the fastest-growing firms in the nation…………………….

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A New Twist in Reference Based Pricing Lawsuits?

July 12th, 2018

“And the verdict is…………….”

This case is instructive for employers who use reference pricing.  It is a good reminder that employers who use reference pricing should confirm that they fall within the guidance for establishing a network and confirm that their administrators are correctly explaining the plan terms to providers who call to determine coverage.

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Mike Dendy Announces Launch of AHPA

July 12th, 2018

I’m pleased to announce the launch of Association Health Plans of America (AHPA).  AHPA will be sponsored by Job Creators Network (JCN) an Association started by Home Depot founder Bernie Marcus to assist small businesses.  JCN has partnered with Dr. Tom Price former Secretary of HHS and the primary author of the AHP regulations and legendary business and sports legend Fran Tarkenton for the development and national deployment of an AHP targeting small employers and using the new regulations to place the group(s) upon an ERISA self-funded platform.

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Health Care Expert Poses Interesting Question

July 12th, 2018

By Mel Schlesinger

Editor: Another interesting observation by Mel Schlesinger: Lower your health care costs by enrolling for a 3 credit hour course at your local college………………………………

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New Cost Containment Strategy? – DIVORCE

July 12th, 2018

The following article is another example of a broken health care system and the lengths some take to find affordable health care…………………..

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TPA Sues Teladoc

July 12th, 2018

An Illinois benefits administrator is suing the telemedicine company Teladoc for $450,000 in overcharges, claiming the company tried to restructure a refund to avoid a negative outlook on its financial statements.

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One Phone Call Later And Presto – Lower Rx Prices for All Americans

July 11th, 2018

“Just talked with Pfizer CEO and @SecAzar on our drug pricing blueprint,” Trump tweeted Tuesday night after arriving in Brussels, Belgium, for the NATO summit. “Pfizer is rolling back price hikes, so American patients don’t pay more.”

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Scheussler Stick™ Sales Explode

July 10th, 2018

The Schuessler Stick™, introduced to the market less than one week ago, is surpassing all sales expectations. It’s rumored to be a “must have” for all the attendees of the upcoming SIIA convention in Austin, Texas. Orders are averaging 2,000 per day.

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The 340B Program

July 10th, 2018

For 25 years, the 340B program has provided hospitals with financial help to expand access to life-saving prescription drugs and comprehensive health care services to low-income and uninsured individuals in communities across the country.

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Getting Away With Murder

July 10th, 2018

“Pfizer & others should be ashamed that they have raised drug prices for no reason,” Trump posted on Twitter. “They are merely taking advantage of the poor & others unable to defend themselves, while at the same time giving bargain basement prices to other countries in Europe & elsewhere. We will respond!”

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Detecting Truth, Deception, and Lies

July 10th, 2018

Most people believe they can tell when someone is lying…………….but some can’t. For example, an insurance agent representing a BUCA tells their client they receive no other compensation other than the disclosed PEPM fee. How can one tell if this is a lie………………?

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Let’s Face It – Scott Sterling Never Gives Up

July 9th, 2018

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David Belk Reports On His RX Findings

July 9th, 2018

David Belk, M.D.

Hello again everyone, I hope you all had a great 4th of July!

I’m writing you all today to give you two updates about prescription medication costs. The first update has to do with the cost of generic prescription drugs: Their prices went down last year! That’s right, down, by an average of about 12%!!

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The Path To Fixing Health Care Starts With Employers

July 8th, 2018

“You don’t need an act of Congress to make a difference when it comes to employer health” – Dave Chase

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The Schuessler Stick™

July 7th, 2018

“I always say I have to carry metal rod with the mirror at the bottom of it to run under my car before crank it up”Carl Schuessler

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Benefits Consultants Group

July 7th, 2018

Delivering comprehensive resources to the advisor community…………………….

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Is Anything But Status Quo Better?

July 3rd, 2018

When things are so bad that anything different than the status quo is considered a good idea…that’s when we find out just how bad it really can get.

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Who Starts Tyrone’s Car In The Morning?

July 3rd, 2018

How many businesses do you know want to cut their revenues in half? That’s why traditional pharmacy benefit managers don’t offer a fiduciary standard and instead opt for hidden cash flow opportunities such as rebate masking. Want to learn more? – Tyrone Squires

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Managing Risk VS Servicing Risk

July 3rd, 2018

Brokers who survive in the long run will adopt both strategies by aggregating best in class services on a private label basis as a single source comprehensive branded model……………………..This will enable independent brokers to effectively compete with the big boys…………………….

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Nurse Hotline Causes Sharp Increase in ER Visits

July 2nd, 2018
One time some years ago I implemented a 24 x 7 nurse hotline for a two hundred thousand life group……..

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PillPack Founders, 32 & 35 To Receive $200 Million From Sale

July 1st, 2018

The two co-founders of PillPack are set to get about $100 million each in the startup pharmacy’s sale to Amazon.com.

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Amazon + PillPack = Major Market Disruption

July 1st, 2018

PillPack is an online pharmacy that packages, organizes and delivers presorted doses of medications.

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