Kasey Raetz, Pharm.D. | PBMI Innovator

Kasey Raetz, Pharmd.D.

"Wouldn’t be a day if I didn’t talk about GLP-1s” laughs Kasey Raetz, Pharm.D.

Like executives at nearly every pharmacy benefit manager (PBM) and payer, Raetz was seeing tsunami-like trends in prescriptions of the now-famous glucagon-like peptide 1 (GLP-1) drugs, which include Wegovy (semaglutide) and Zepbound (tirzepatide) for weight loss and the same drug marketed under different names for diabetes but used off-label for weight loss.

“I’ve never seen a category with so much demand,” Raetz continues. “And every person in America, whether they’re in the industry or not, can name these drugs, which is just incredible. We just have never seen this before.”

Raetz, who sports a mouthful of a title, vice president of product and pharma contracting and strategy at Express Scripts, and her team of 50 people went to work on creating a GLP-1 program.

Called EncircleRx, it has three components, according to Raetz: ensuring that appropriate patients have access to the GLP-1 medications for obesity, additional tools for patients to help them stay on the drugs so they can be “more successful on their weight-loss journey,” and financial protection for the health plans.

“We put a financial guarantee out there for our plans so that they could budget appropriately for these drugs, and if we got it wrong, we’re on the hook for those dollars,” says Raetz.

She says one of the “flavors” of the financial provisions of EncircleRx is a 3-1 return on investment: what they pay into the program, Express Scripts delivers at least three times that in savings. Raetz says 500 clients have signed up for the program since it launched in January 2024.

Although every PBM has had to respond to the surge in GLP-1s, Raetz says the industry didn’t have a solution when she started working on EncircleRx.

Her leadership of the program and others is the reason Managed Healthcare Executive and the Pharmacy Benefit Management Institute (PBMI) have selected Raetz, 35, for the inaugural PBMI Innovators Award, which recognizes people bringing new ideas and initiatives to pharmacy benefits.

Raetz’s experience with EncircleRx made her fall for Express Scripts during an internship between her second and third years of pharmacy school at Southern Illinois University Edwardsville.

She had been working at an independent pharmacy in Illinois. She enjoyed working with patients and building relationships with her regulars.

But Express Scripts hit her at a different level. “I loved it,” says Raetz. “It was 180 degrees from what I was doing — not just managed care, but corporate America. The whole knowledge base and skill set was not something I was accustomed to. I really enjoyed understanding the business, the financial side of things and the inner workings of the industry.”

The people she met and worked with were “just awesome, very welcoming, very smart.”

'I can help you with that'

When Raetz graduated from high school in Wisconsin, she had no notion of becoming a pharmacist, let alone working for a PBM. After growing up in the small southeastern Wisconsin city, Raetz didn’t follow the herd to the University of Wisconsin when she came out of high school.

Instead, she headed for Columbia, Missouri, and the University of Missouri. She had her sights on medicinal chemistry and a career in research and development, “creating new molecules and going through the research process.”

But by the time she was a junior and senior, Raetz said she realized that long hours in a lab “on the bench” didn’t appeal to her. She continued with her chemistry major so she would have a backup plan, but her ambitions slid over to pharmacy school and getting her Pharm.D. degree. Her solid foundation in chemistry made parts of pharmacy school a relative breeze.

“I had a lot of really good friends as we were going through therapeutics, and they were, like, ‘Oh my gosh, this chemistry is out of control.’ I was like, ‘Oh, I can help you with that.’”

Express Scripts had some “PBM 101” courses that provided some basic information about what PBMs do, but Raetz learned about the complicated industry by taking on tasks and responsibilities.

One was a program addressing an issue in compounding, where “extraneous ingredients” were being billed at very high costs. Raetz worked on programs to clamp down on the problem. She also dived into prior authorizations and how to automate them using International Classification of Diseases codes.

She also found that she enjoyed grappling with the pharmacy benefit issues that arise in the treatment of rare diseases such as hemophilia and hereditary angioedema.

That interest has continued, with Raetz and her team managing Express Scripts’ Embarc Benefit Protection program, which is designed to protect plans and members from sudden high costs of gene therapy by having plans pay a set per-member, per-month fee. Her team also has oncology and value-based contracting programs in its remit.

EncircleRx, the GLP-1 program, has gotten off to a strong start, but in the 18 months since its launch, Raetz and her team have made adjustments. They added vendors to deliver the digital components that help patients with lifestyle modification. They came up with a menu of different utilization management rules because some clients have more restrictive rules than others.

Additionally, they added a program for Medicare Part D plans that want a program for their patients with diabetes who are taking GLP-1 therapies.

“The list goes on and on. My team is a little exhausted at this point, but we continue to flex with the market.”

PBM proud

Raetz and her husband, Matt, have three children, ages 5, 7 and 18. They live in a small town in Southern Illinois, about an hour from Express Scripts’ headquarters.

“We are very busy. And I don’t necessarily call it work-life balance. I call it work-life integration. Express Scripts is a great place to work. The flexibility they give me to have my family and make time for my kids is definitely crucial.”

When Raetz started working at Express Scripts, PBMs were tucked in a corner of U.S. healthcare, largely unknown to anybody but insiders who dealt with pharmacy benefits. But now they have been the subject of a Federal Trade Commission inquiry, numerous congressional hearings and countless news stories.

Raetz says the limelight is different, and she thinks it can be traced back, in part, to people being more knowledgeable about healthcare — and dealing with costs because of the greater number of people enrolled in high-deductible healthcare plans.

“How do I feel about working for a PBM? Proud. I remain proud of everything that we do to help patients get the care that they need when they need it and deliver on our commitments to our plans. Our plans, our employers, our health plans — they hire us to manage this very complicated system and complicated benefits. And you know, we always talk internally: if we weren’t doing our job, we would get fired, and we haven’t gotten fired, right?