Payer policy monitoring that reads every PA criterion and checks every change against what the plan contracted
Every payer policy change caught within a day of posting, and checked against what the plan contracted.
See one case, screen by screen ↓Plans and PBMs post a new medical policy, a formulary file or a preferred drug list revision whenever their P&T committee meets — on their own sites, in PDFs, in spreadsheets, on their own schedule. A new step through a competitor, a higher threshold or a shorter approval length can take effect a few weeks later. The access commitment in the rebate agreement says the plan should have given 60 days’ notice. Often nobody on the manufacturer side has read the new version yet.
So the change surfaces at the quarterly policy review, or when hub cases start coming back denied and the field calls in. By then patients have been turned away, the notice and cure period has started to slip, and the payer analytics team is rebuilding the criteria grid by hand — one policy, one indication, one criterion at a time — before anyone can say which plans are breaking which term, and for how many lives.
Estimated split for one adverse change on a contracted plan, with a quarterly policy review and with the solution. The quarterly-review baseline is an estimate.
Six specialist agents fetch, read and compare every policy change, size its reach and check it against the contract; the payer intelligence lead confirms before any notice goes out.
Crestline Health posts revision 14 of its psoriasis biologics policy on Oct 5, effective Nov 1. Here is what happens next, screen by screen, in the working solution.
Lena opens the coverage pulse for Veltrimab and Corventa: 412 policies across 64 plans and PBMs. Three changes need her — Crestline, Bluepeak and Harbor — two plans are not meeting contract terms across 25.5M covered lives, and 92% of US lives have contracted access to Veltrimab in psoriasis — 89% once the published changes apply.
Change wire: “Crestline Health · Step through Ostrelix added before Veltrimab” — “Veltrimab · Psoriasis · effective Nov 1 · caught 26 h after posting.”
The morning sweep fingerprints RX-PSO-117 and sees new content: revision 14, approved by P&T on Sep 29, posted Oct 5, effective Nov 1. The other agents take it from there — 14 pages and 9 criteria read, 4 criteria changed, 2 contract terms not met, 3.1M lives and 212 open hub cases on the plan.
How the agents found it: Policy Watcher 0.8 s · Criteria Extractor 6.2 s · Version Comparer 2.1 s · Contract Guard 3.4 s · Impact Estimator 0.9 s.
Against revision 13 of Jan 1, 2026: the step goes from one TNF inhibitor to one TNF inhibitor plus Ostrelix, body surface area from 3% to 10%, re-authorization from 12 months to 6, and the notice given is 27 days against the 60 required. Age, dermatologist prescriber, TB test, no combined biologic and the quantity limit are listed as unchanged.
Old and new side by side — unchanged criteria are listed as unchanged.
Lena clicks the new step and the passage opens where it lives: page 3 of RX-PSO-117 rev 14, criterion B.4, from the stored version fingerprinted on fetch. Every field in the criteria database carries its page and line, and anything read below 0.85 confidence goes to a person.
“The member has had an inadequate response, intolerance or contraindication to ONE preferred TNF inhibitor AND to Ostrelix.”
§4.2 of the Crestline 2026 Commercial Formulary Agreement says the plan shall not require a member to try or fail any Competitive Product before Veltrimab — and Exhibit B names Ostrelix. §7.1 asks for 60 days’ written notice of a utilization management change; 27 were given. The 10% BSA threshold is flagged under §4.5 as stricter than the label, but not counted as a breach: it matches Ostrelix’s own criteria, so parity holds.
Flagged for you, not counted as a breach.
3.1M covered lives on Crestline, 1,840 patients on Veltrimab on the plan, 212 open hub cases and about 38 new patients a month at risk — the last one marked as an estimate. Counts only: no patient detail leaves the hub.
“From Nov 1 every patient re-authorizes every 6 months — 1,840 re-authorizations a half-year instead of a year.”
The agents propose, a person confirms. Lena presses “Confirm and draft notice” — “Not a breach” would close it with her reason, kept with the alert. The Notice & Brief Writer drafts the notice of non-compliance in the legal-approved template, with 5 citations: what changed, the terms not met, and what Crestline is asked to do before Nov 1.
§9.3: if the failure is not cured within 30 days of the written notice, access rebates may be suspended for each quarter it continues.
Lena sends the draft to Sam to sign, with Dana Okafor copied for the cure clock. Sam signs electronically and the notice goes out; the 30-day cure period ends Nov 6. From now on 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.”
Crestline: 30 days left to cure, ends Nov 6. Northgate Rx, where the 2027 formulary puts a TNF step on Veltrimab in Crohn’s but none on Dravimab: 28 days left, ends Nov 4. Silverpine MA and Marlowe Health tightened access too, but there is no access agreement with either, so they sit with the account team with no contract clock.
Bluepeak Medicare Rx removes the TNF step for Veltrimab in psoriatic arthritis for 2027 — better than contracted. The Notice & Brief Writer drafts the field brief from approved coverage wording: what changed, who it affects, what offices need to send. It goes to Dr. Maya Chen for approval before field reimbursement and hub teams see it.
“Approved coverage wording only. Do not predict approval for an individual patient. Refer clinical questions to Medical Information.”
The same policy change, seen by the people who carry it — what their week looked like, and what it looks like now.
Six specialist agents fetch, read and compare every policy change, size its reach and check it against the contract; the payer intelligence lead confirms before any notice goes out.
Fetches 412 payer policies, PBM formulary files and Medicaid preferred drug lists on schedule and spots a new version by its content, ignoring page furniture such as footer dates.
Reads each policy and fills the criteria for every drug and indication — formulary status and tier, PA, steps and named agents, thresholds, prescriber, labs, approval length, quantity limits, site of care.
Builds the redline between the old and new policy, lists each changed criterion, classifies it as adverse, favourable or administrative and counts the notice given.
Adds covered lives, patients on therapy and open hub cases on the plan, 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.
Drafts the notice of non-compliance for the account director and the field brief for compliance approval — 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 cites the policy or the clause it rests on.
What changed at Crestline Health?
Revision 14 of RX-PSO-117 (psoriasis biologics) was posted Oct 5 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. Two terms are not met: §4.2 forbids a step through a competitor, and §7.1 needs 60 days’ notice — 27 were given. 3.1M lives.
Which plans are breaking our contract terms?
Two: Crestline Health (step through a competitor, 3.1M lives) 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 there is no access agreement with them.
How fast do we catch changes?
Median 0.9 days — about 21 hours — from a plan posting a policy to the alert over the last 30 days; Crestline was caught 26 hours after posting. The sweep runs every 4 hours over 412 sources. 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 new 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 are settings, changed in a minute and recorded in the audit trail.
| Setting | Default | Choose from |
|---|---|---|
| Sweep schedule | Every 4 hours (06:00, 10:00, 14:00…) | Every 4 hours · Daily at 06:00 · Weekly on Monday |
| Who decides a contract breach | Lena Ortiz → account director | Lena Ortiz → account director · Account director only |
| An adverse change goes to “Needs you” when the plan covers at least | 500,000 lives | 500,000 · 1 million · 2 million lives |
| Who approves field briefs | 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 |
| Push new PA forms to open hub cases | On | Hub cases on the plan get the new form and a note |
| Licensed formulary data feed | On | Optional vendor feed for covered lives and tiers · licence terms apply |
| Watch rules | Any step through a competitor product · approval length shortened · new PA form version | Describe a rule in plain words |
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 plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published payer-intelligence analyses (claims data shows a policy change 60–90 days late; the quarterly-review baseline is an estimate). People, plans, products and companies named on this page are characters in the working solution.
Watching payer and PBM medical policies, formularies, preferred drug lists and PA forms for new versions, reading what changed for each drug and indication, and acting on it. The Payer Coverage Policy & PA Criteria Monitor does this on a schedule with six agents and checks every change against the plan’s access commitments.
The Criteria Extractor reads each policy and fills the criteria for every product and indication — formulary status and tier, PA, step therapy and the named agents, clinical thresholds, prescriber specialty, labs, initial and renewal approval length, quantity limits and site of care. Every field carries its page and line, it never infers a criterion that is not written, and anything below 0.85 confidence goes to a person.
The Contract Guard reads the plan’s access terms from your contract system — competitor steps, parity with named products, PA no stricter than the label, notice and cure periods — and decides for each changed criterion whether the term is met, not met, or needs a person. It quotes the clause and the policy passage side by side.
No. A person confirms every breach, the account director signs every notice, and field briefs need access compliance approval before release. The agents draft and check; people decide, and every decision is on the activity trail.
Payer portals and medical policy PDFs, PBM formulary files with exclusion lists and UM criteria, Medicaid preferred drug lists and PA request forms — plus an optional licensed formulary feed for covered lives and tiers, used within its licence terms.
The design goal is a median of 0.9 days from a plan posting a policy to a cited alert, with 412 policies checked every 4 hours. In the working solution, Crestline Health’s revision was caught 26 hours after posting. The sweep schedule is a setting.
No. The Impact Estimator works with counts only — covered lives, patients on therapy and open hub cases on the plan — and marks estimates as estimates.
The Agentic Solution Engine builds and deploys it from your requirements — your watch list, your products and indications, your access commitments and notice template — and it goes live once every quality gate has passed. We will walk you through it on your own plans first.
A global value dossier drafted section by section, with every sentence linked to its source and checked against the label.
1-min filmRebate ValidationEvery rebate invoice line checked against the contract, and every dispute backed by its clause.
1-min filmPayer ContractsEvery payer contract and amendment becomes cited terms in force, with every deadline on a clock.
1-min filmWe’ll run the Coverage Policy Monitor on your own watch list and access commitments.