Payer coverage policy tracking that catches every PA criteria change within a day of posting — checked against the contract
Every payer policy change caught within a day of posting, checked against the contract.
See one case, screen by screen ↓Watching payer medical and pharmacy policies, PBM formularies and Medicaid preferred drug lists for changes to the coverage and PA criteria of your products. Payer Coverage Policy Tracking adds six agents that fetch every source, read each new version into criteria, compare it with the last, check it against the plan's contract and show on a US map which states it moves.
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Payer medical and pharmacy policies, PBM formularies and Medicaid preferred drug lists change every week, and quietly: a new revision on a payer portal, a new PA request form, a quantity limit file, a P&T decision folded into next year's formulary. The access team reads them through weekly feed e-mails and spreadsheets, abstracts the PA criteria by hand and compares them with the contract at the quarterly business review.
By then the effective date has often passed, the contract's notice window has closed and patients are already being denied. A step through a competitor, a parity break with a rival product or 25 days' notice against the 60 the agreement requires is only enforceable if someone sees it in time — and the cure clock only starts when the notice of non-compliance goes out.
Estimated hours for one material change on a commercial plan, by hand and with the solution.
Six specialist agents fetch, read and compare every new policy, check it against the contract and show the states it moves; the payer intelligence lead confirms before any notice goes out.
Wednesday, Oct 7. Crestline Health — a commercial plan with 3.1M lives in Ohio, Kentucky and West Virginia — posts revision 14 of its psoriasis biologics policy at 08:40, effective Nov 1. Here is what happens next, screen by screen, in the working solution.
Lena's home screen is a US map of where patients can get Veltrimab for plaque psoriasis as contracted, across 412 payer policies, PBM formularies and Medicaid lists in 64 plans. The 09:12 check of the 31 plans over 1M lives finds RX-PSO-117 revision 14. On the change wire the agents fetch 14 pages, read 9 criteria for Veltrimab, compare them with revision 13 and check the Crestline 2026 agreement: 4 criteria changed, 2 terms not met.
On the wire: “Step therapy · 1 TNF inhibitor → 1 TNF inhibitor + Ostrelix · New step · competitor.”
As posted, Ohio drops from 97% to 79% of lives with contracted access, Kentucky from 95% to 77% and West Virginia from 97% to 79%; nationally the view falls to 93%, one point below today's 94% in force. Lena clicks Ohio: Crestline Health carries 2.02M lives there, now marked “Step through a competitor”, beside Northgate Rx, Harbor Union Rx and Bluepeak Medicare Rx.
Lives-weighted, per product and indication — in force today or as posted.
The review opens on the policy redline. Step therapy now needs ONE preferred TNF inhibitor AND Ostrelix; body surface area rises from 3% to 10%; re-authorization falls from 12 months to 6; the notice given is 25 days. The five unchanged criteria are listed too — age 18 or older, dermatologist, negative TB test, no other biologic, 1 syringe per 56 days. Each agent step is timed in the trace.
The Version Comparer always lists the criteria that did not change.
§4.2 of the Crestline 2026 Commercial Formulary Agreement says the plan shall not require a member to try or fail any Competitive Product — and Exhibit B names Ostrelix. §7.1 requires 60 days' notice of any utilization management change; Oct 7 to Nov 1 is 25. The 10% BSA threshold is flagged as stricter than the label, but it matches Ostrelix's own criteria, so parity holds — flagged, not counted as a breach.
The Contract Guard never decides a breach — a person confirms.
Crestline covers 3.1M lives; 1,840 patients are on Veltrimab on the plan, 212 hub cases are open and about 38 new patients a month are at risk — marked as an estimate. From Nov 1 every patient re-authorizes every 6 months: 1,840 re-authorizations a half-year instead of a year. The counts come from the hub; no patient data leaves it.
Lena chooses “Confirm and draft notice”. The Notice & Brief Writer drafts a notice of non-compliance from Sam Patel to Crestline's pharmacy and formulary leadership on the legal-approved template: what changed, the terms not met, and what Northwind Bio asks — remove the Ostrelix step before Nov 1 and confirm in writing within 30 days, or §9.3 allows access rebates to be suspended.
“The notice is drafted with 5 citations. Sam signs; the cure clock starts when it is sent.”
Lena sends the draft to Sam Patel, with Dana Okafor copied for the cure clock. Sam signs electronically and the notice goes to Crestline Health. Dana starts the 30-day cure clock, which ends Nov 6, and the Contract Guard re-checks the Crestline policy every sweep until it is cured.
“Signed and sent Oct 7 · 09:12 by Sam Patel · cure by Nov 6.”
The change's activity lists who did what and when: the Policy Watcher finding revision 14, the Criteria Extractor reading 14 pages, the Contract Guard quoting §4.2 and §7.1, Lena confirming, the Notice & Brief Writer drafting with 5 citations, Sam signing and Dana starting the clock. Agent steps are marked AI; people by name.
Not every change is adverse. Bluepeak Medicare Rx removes the TNF step for Veltrimab in psoriatic arthritis for 2027 — better than contracted. Lena drafts a field brief: what changed, who it affects, what offices need to send (diagnosis, prescriber specialty, a TB screen from the last 12 months). It goes to Dr. Maya Chen for approval before it reaches the field.
“Approved coverage wording only. Do not predict approval for an individual patient. Refer clinical questions to Medical Information.”
Between scheduled sweeps Lena can check every source. The Policy Watcher fetches all 412: 411 unchanged and one new version, a Cobalt Care formulary update. The agents read 9 pages, find Corventa added as preferred in ulcerative colitis after one TNF inhibitor, price it at 0.7M lives and 4 open hub cases, and find it as contracted — a new alert on the change wire.
The same policy change, seen by the five people who act on it — what their week looked like, and what it looks like now.
Six specialist agents fetch, read and compare every new policy, check it against the contract and show the states it moves; the payer intelligence lead confirms before any notice goes out.
Fetches 412 payer policies, PBM formulary files and Medicaid preferred drug lists — the 31 plans over 1M lives every hour, all 412 every 4 hours — and spots a new version by its content, ignoring page furniture such as footer dates and navigation.
Reads each policy into criteria for every product and indication: formulary status and tier, PA, every step with its named agents and whether one is a competitor, thresholds, prescriber, labs, approval length, quantity limits and site of care.
Compares the new criteria with the last version field by field, builds a redline of the policy text, classifies each change as adverse, favourable or administrative, and counts the notice given between posting and effective date.
Adds the plan's covered lives, patients on therapy and open hub cases, so the team sees what a change is worth.
Checks every changed criterion against the plan's access commitments — competitor steps, parity, label-level PA, notice periods — and quotes the clause and the policy passage side by side.
Drafts the notice of non-compliance for the account director on the legal-approved template, and the field brief in approved coverage wording for compliance — every statement cited.
Confirms; the account director signs. The agents propose; a named person decides.
Ask in plain words — or tell it what to watch. Every answer points to the policy page or contract clause it came from.
What changed at Crestline Health?
Revision 14 of RX-PSO-117 (psoriasis biologics) was posted this morning at 08:40 and takes effect Nov 1. Three criteria tighten for Veltrimab: a step through Ostrelix after one TNF inhibitor, body surface area 3% → 10%, and re-authorization 12 → 6 months. The Contract Guard found two terms not met: §4.2 forbids a step through a competitor, and §7.1 needs 60 days' notice — 25 were given. 3.1M lives.
Which plans are breaking our contract terms?
Two right now: Crestline Health (step through a competitor, 3.1M lives, waiting for your confirmation) and Northgate Rx (parity with an IL-23 competitor, 22.4M lives). Northgate's notice went out Oct 5 — the cure period ends Nov 4. Marlowe and Silverpine tightened access too, but we have no access agreement with them.
How fast do we catch changes?
Median 0.9 days from a plan posting a policy to our alert over the last 30 days; Crestline was caught 32 minutes after posting. Plans over 1M lives are checked every hour; the full sweep of 412 sources runs every 4 hours, with 0 failures this morning. Before, changes surfaced at the quarterly review — often 45–90 days later (an estimate, not a measured baseline).
Alert me when any plan adds a step through Ostrelix
Done — a watch rule “Step through Ostrelix before Veltrimab or Corventa”, all 64 plans, alert immediately and route to the account director. Today one plan matches: Crestline Health. The rule is in Settings, where you can switch it off.
13 screens from the working solution, on its sample data. Pick one to see it large.
What the agents watch, who decides and how alerts are routed — each a setting, with watch rules written in plain words.
| Setting | Default | Choose from |
|---|---|---|
| Full sweep of all 412 sources | Every 4 hours (06:00, 10:00, 14:00…) | Every 4 hours · Daily at 06:00 · Weekly on Monday |
| Large plans checked every hour | On — 31 plans and PBMs over 1 million lives | On · Off |
| Contract breach | Lena Ortiz → account director | Lena Ortiz → account director · Account director only |
| Adverse change on a large plan goes to “Needs you” at | 500,000 lives | 500,000 lives · 1 million lives · 2 million lives |
| Field briefs approved by | Dr. Maya Chen · access compliance | Dr. Maya Chen · access compliance · Omar Haddad · field reimbursement |
| Close label-matching changes automatically | On — quantity limits and specialist rules that match the label need no review | On · Off |
| Push new PA forms to open hub cases | On — hub cases on the plan get the new form and a note | On · Off |
| Licensed formulary data feed | On — optional vendor feed for covered lives and tiers | On · Off |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample plans and policies · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (Tufts SPEC analysis of commercial specialty drug policies — 51.7% stricter than the FDA label in 2021; a market-access analytics vendor's published estimate — claims data show a payer change 60–90 days late). People, plans, products and companies named on this page are fictional — characters and sample data in the working solution.
Watching payer medical and pharmacy policies, PBM formularies and Medicaid preferred drug lists for changes to the coverage and PA criteria of your products. Payer Coverage Policy Tracking adds six agents that fetch every source, read each new version into criteria, compare it with the last, check it against the plan's contract and show on a US map which states it moves.
Plans over 1M lives are checked every hour and all 412 sources every 4 hours; in the working solution Crestline's revision was found 32 minutes after posting. The design target is a median of 0.9 days from posting to a cited alert.
The Criteria Extractor fills status, tier, PA, every step with its named agents and a competitor flag, thresholds, prescriber, labs, approval length, quantity limits and site of care — each with its page. Criteria below 0.85 confidence go to a person, and nothing that is not written is inferred.
Yes. The Contract Guard reads the plan's access terms from the contract system — competitor steps, parity, label-level PA, notice periods — and quotes the clause beside the policy passage. It proposes; the payer intelligence lead confirms every breach.
No. The Notice & Brief Writer drafts; the account director signs every notice of non-compliance, and access compliance approves every field brief, which uses only approved coverage wording and makes no efficacy claims.
Yes. A person confirms every breach or records “not a breach” with a reason, the account director signs, compliance approves what reaches the field, and every agent step and decision is on the activity trail.
No. The Impact Estimator uses counts — covered lives, patients on therapy and open hub cases — and labels its estimates.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your products and indications, the plans and sources you watch and your access agreements — and it goes live once every quality gate has passed. We will walk you through it on your own plans first.
Every GVD sentence linked to its source and checked against the label.
1-min demoRebate Claims ValidationEvery rebate invoice line checked, every dispute backed by its clause.
1-min demoPayer Contract ManagementEvery payer contract turned into cited terms, every deadline tracked
1-min demoWe'll run Payer Coverage Policy Tracking on your products, your watch list and a sample of your access agreements.