Lightly edited for clarity.

[00:23] Justin Venneri: Hello, and thank you for listening to this episode of Astonishing Healthcare, episode 120. It is crazy how fast time flies, and this one is going to be on a pretty technical topic, but it's an important one. As far as I can tell, it impacts everyone involved in the pharmaceutical supply chain, especially on the administrative side. It's the NCPDP D.0 to F6 transition, and I'll get my subject matter experts who are with me to explain this in a little bit more detail.

We're going to try to cover, at a high level, what the pharmacy benefits industry needs to know and what people can put on their calendars to do next. To be fair, if you're in the industry, you've probably heard about this and may have started preparing, but it's right around the corner, and I think this is a good Q&A.

So here we are. I've got Brandie Wright on our legal and compliance team with us, and Paul Furman as well on the data side. They're in the studio with me to talk this through. Brandie and Paul, thanks for joining me today.

[01:12] Brandie Wright: Thank you for having us.

[01:14] Paul Furman: Excited to be here. Thank you.

[01:15] Justin Venneri: So, Brandie, starting off with you, tell us a bit about your background and your role here at Judi Health.

[01:20] Brandie Wright: Yes. So I am a Regulatory Affairs Manager on the regulatory affairs team here at Judi Health. I came here in April of 2024, so it's been about two and a half years now. I've been helping to build out our regulatory change management process for new regulatory changes that impact us and our clients for commercial lines of business. Before that, I was in healthcare for about 16 years. Directly prior to this, I was with a PBM for six years before making the jump to Judi.

[01:51] Justin Venneri: Awesome. We're happy to have you. And Paul, how about you tell us a bit about your background and your path to Judi Health?

[01:57] Paul Furman: Of course. Thank you very much for the opportunity. I'm Paul Furman, VP of Data Management, and I've been with Judi Health for a bit over three years. While that is still considered relatively new compared to other people in the PBM business, I'm not new to healthcare and definitely not new to data. I've been working with different flavors of data in data management, data engineering, data analytics, and other flavors of data.

[02:19] Justin Venneri: So, big picture, Brandie, let's unpack this F6 topic — the D.0 transition. Can you share some high-level background on what's happening here and some of the key dates, please?

[02:29] Brandie Wright: Sure. So, at a high level, the move from D.0 to F6 is really about modernizing the pharmacy transaction standard. D.0 was developed back in 2007 and has been the required federal standard since about 2012. So the industry has been operating under that framework for over a decade.

Since then, the pharmacy landscape has changed significantly, as we all know. From a regulatory standpoint, HHS — Health and Human Services — formally adopted F6 in its final rule adoption back in December of 2024. So that's when they published the final rule. This rule became effective April 14, 2025, and then the industry has to start implementing it and has a transition period from August 14, 2027, until full compliance needs to be adhered to by April 14, 2028.

[03:25] Justin Venneri: Thank you for that. Brandie, definitely right around the corner. This is how all of these transactions are processed. Can you talk to us a little bit about what happens behind the scenes when someone fills a prescription? And is there anything you'd add to what Brandie explained?

[03:38] Paul Furman: Absolutely. There's a lot happening in those few seconds at the pharmacy counter. But in simple terms, the claim goes out, the member's benefits and coverage are evaluated, and the pharmacy gets a response back almost immediately telling them whether it can be processed and what the member owes.
While that is relatively straightforward, the bigger challenge is coordination. Changing our technology is manageable, but we don't operate in isolation. Everyone exchanging these transactions has to make the change together without disrupting prescriptions for members. In addition, data exchanges will be greatly affected, as many files are exchanged in specific or fixed-width formats that might not be flexible enough to accommodate these changes right away.

[04:20] Justin Venneri: Interesting. Brandie, what couldn't D.0 — and that's NCPDP D.0, right?

[04:27] Brandie Wright: Yes.

[04:27] Justin Venneri: Yeah. What didn't that adequately accommodate? Just curious about the background and reasoning, or your opinion there.

[04:33] Brandie Wright: So I think the biggest reason for this transition is that we've seen a lot of changes in the way that pharmacies adjudicate claims from 2007 to now. For example, one of the limitations that D.0 has is financial capacity. We now have specialty and gene therapies that can cost hundreds of thousands, if not millions, of dollars. Originally, D.0 wasn't designed for transactions of that size.

At the same time, pharmacy benefits themselves have become more complex. We have more complicated coordination of benefits and payment arrangements. We have manufacturer assistance programs and copay card programs. So there's a lot of complexity within the pharmacy industry that didn't exist originally when D.0 was developed.

[05:28] Justin Venneri: Paul, anything you'd add to that? Any other examples that come to mind of why this is necessary in the upgrade? How big of a difference is the jump from D.0 to F6?

[05:37] Paul Furman: Richer and more precise data can make a real difference when determining whether a prescription is covered, calculating the member's correct cost at the pharmacy, or making sure the claim is processed using the right drug and benefit information. That is, in essence, the most important part of the adjudication process.

And yes, there are quite a few differences between the old format and the new format. As far as I remember, there are 200 new fields, 150 modified fields, and about 50 removed fields, in addition to updated codes and business rules. That means the effects extend beyond the core claims engine into systems and processes consuming or interpreting pharmacy transaction data.

One visible change is the routing transition from a six-byte BIN — the bank identification number — to an eight-byte IIN, which is the issuer identification number. That then impacts spreadsheets, member ID cards, etc.

[06:33] Justin Venneri: That was interesting to me because I know that's one of those things everybody always asks when you call: "I need your member ID, I need the BIN." That seems like a pretty big change. I assume there's much more, and I will add some links to the show notes for reference materials that are pretty dense.

But this seems like a pretty technical compliance exercise. Is there a bigger opportunity here, Brandi, to improve things along the lines of compliance, data access, et cetera? I mean, it does go down to the actual transaction level. So I'm not sure how much of this is involved with some of the other data and reporting requirements that we've seen passed into law recently, but you're the expert there, so you tell us.

[07:11] Brandie Wright: So compliance is obviously what's driving this timeline and how quickly it's moving. I do think there is a bigger opportunity here than just adhering to this. F6 is giving the industry a much richer and more precise data set than what we have today. So that creates more opportunities for us to improve claims adjudication, how coordination of benefits are handled, how information is communicated back to the pharmacy at the point of sale, and it gives PBMs like us and health plans better data for downstream reporting, analytics, and operational oversight.

So I only see this as advancing the industry, which I know Judi [Health] is all about.

[07:52] Justin Venneri: Good stuff. Paul, given all these changes and the timeline we reviewed, who needs to be at the F6 table, so to speak, inside an organization to review what needs to be done and when?

[08:03] Paul Furman: I think practically everyone, starting with data, product, core adjudication, client service, management teams, the entire technology team — like I said, practically everyone.

[08:12] Justin Venneri: Wow. Okay. Brandie, anything you'd add there?

[08:15] Brandie Wright: I was going to say everyone, just because of how many areas this touches. This is our entire framework, so I think everyone needs to be engaged.

[08:26] Justin Venneri: Even I get pulled into it from a communications and content perspective, so it literally is everyone. That's great. And Paul, I think a good follow-up on that is: what should a sophisticated client — and it does impact pretty much everybody, so maybe it's broader — what should clients be asking their PBM, their TPA, or technology partners about F6 readiness right now?

[08:47] Paul Furman: If I were a sophisticated client, I would ask my technology partner about the timelines and plans to support this transition, and also how they can help us. There is a lot to do. How can we coordinate our efforts to make it simpler and easier for all of us and make sure that we do not reinvent the wheel on a daily basis?

[09:07] Justin Venneri: That makes sense. We were talking about the dates earlier. A couple of questions in one here — I like to do that to my guests. Sorry about that in advance. What else should everyone put on their roadmap right now? The questions that they should be asking, as you just outlined — I assume testing and deployment need to be highly coordinated. Could you elaborate on that a little bit, Paul?

[09:25] Paul Furman: I would say that data validation is going to be one of the most impacted areas for our teams, whether it's a core adjudication team or data or data exchange. We can make changes to our code base, but we have to review every data element and every report, inbound or outbound, to make sure that the data is compliant and that we have all of the elements and all of the changes captured.

[09:54] Justin Venneri: Got it. It's a big lift. Just two more questions for you. Thank you both so much for taking the time. I know you're both busy. I really appreciate that you could jump in the studio with us today.

If someone realizes today that their organization hasn't done much, or they're not aware of this, maybe they feel like they're not doing enough or they didn't know what was going on, what should rise to the top of the list? What should they do next? Paul?

[10:14] Paul Furman: Strictly from the data management perspective, revisiting any data and file formats that are not flexible enough to accommodate the new changes would be at the top of the list.

[10:24] Justin Venneri: Okay. Are there reference files? I think it lays out in some of the longer documents. Brandie, maybe you're nodding your head. What would you add onto what Paul just advised?

[10:34] Brandie Wright: Yeah. NCPDP has collaborative workspaces where a lot of health partners and a lot of people in the industry are collaborating, trying to work out exactly how to implement this across different platforms, especially those that are more dated versus those that are more modernized. At this point, they have thousands of documents, but they have a lot published to help facilitate understanding. They're also open to questions about how to adhere as well.

[11:08] Justin Venneri: No, that's pretty cool. I did see some kind of Q&A in those documents where it's like a good question and they go into a detailed answer.

Last question. Instead of the typical "what's the most astonishing thing?" final question, those of you listening today will be either happy or disappointed, depending on your take here. I want to try a twist. If we fast-forward to mid-2028, what would make you say an organization handled this D.0 to F6 transition astonishingly well? Paul, want to take that first?

[11:34] Paul Furman: Sure. Obviously, we need to ensure that claims are adjudicated properly. From the data and data management perspective, I would say that 100% of our adjudication data and data exchange files are 100% compliant and compatible with new formats, and our clients accepted these new files into their systems. We don't want to cause any disruption to healthcare.

[11:55] Justin Venneri: Got it. And Brandie, same question to you. Please close us out.

[11:59] Brandie Wright: All right. If we fast-forward to mid-2028, I think a successful F6 transition should be very uneventful. As Paul said, there should be no disruption to members, pharmacies, clients, or any of our trading partners. Ultimately, I think success would mean that this transition is very smooth, stays compliant, and has a great monitoring process. All the work that's done behind the scenes should remain behind the scenes so our members and pharmacy partners have a seamless experience and barely notice.

[12:32] Justin Venneri: That would be ideal. Well, Paul and Brandie, thank you so much for joining us in the studio today to talk about this new transition. We look forward to staying in touch and seeing how things are going, and hopefully we're going to have you back in the studio. I expect this will be a good starting point for some iterative content on this topic as we get closer to these key dates in 2027.
So thank you very much, and hope you both have a great rest of your day.

[12:54] Brandie Wright: Thank you so much.

[12:55] Paul Furman: Thank you very much for having us. Have a great day.

[12:59] VO: Thank you for listening to Astonishing Healthcare. Head over to Judi Health and visit the Insights section for show notes and other relevant content. If you liked this episode, be sure to subscribe so you don't miss the next one. And definitely share the link to this show with your network. Have a great rest of your day.