Forward to: Payer Relations

Payer & Insurance Intelligence
Workflows

Ten agent workflows for the Payer Relations team — automated health plan monitoring, formulary change tracking, reimbursement landscape analysis, payer strategy intelligence, prior authorization policy detection, PBM consolidation tracking, Medicare Advantage expansion monitoring, Medicaid managed care analysis, employer benefit trend detection, and payer technology adoption assessment — providing comprehensive domain-level payer intelligence.

1Health Plan Formulary Monitoring

AI agent continuously monitors health plan websites for formulary updates, tier changes, prior authorization requirements, and step therapy protocols that impact drug access and reimbursement.

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Scan Formulary Pages Across Plans
/products/docs/press/compliancePersonas
FORMULARY CHANGE DETECTION — Q1 2026 ════════════════════════════════════════════════════════════ PLANS MONITORED: 347 health plan domains FORMULARY CHANGES: 89 detected in last 30 days unitedhealthcare.com /docs: GLP-1 prior authorization criteria tightened /products: Preferred formulary updated — 3 brand exclusions /press: New step therapy requirement for specialty oncology anthem.com /docs: Biosimilar preferred over reference product for 4 classes /products: Specialty pharmacy network narrowed to 3 vendors /compliance: CMS audit findings — formulary access remediation
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Assess Formulary Impact
Formulary Signal
GLP-1 Access Tightening — 4 of top 5 health plans added PA requirements for GLP-1 obesity indication in Q1 2026. Domain analysis shows /docs pages now requiring BMI >35 + comorbidity documentation. Step therapy through lifestyle modification added by 3 plans. Projected coverage reduction: 28% of eligible patients.
RESTRICTING — GLP-1 access barriers increasing across major plans
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Track Formulary Changes Over Time
Formulary Evolution — GLP-1 Class
2025-07-01 Open access at most plans — no PA for diabetes indication
2025-10-15 First PA requirements for obesity indication appeared on UHC /docs
2025-12-01 Anthem, Cigna added step therapy — /products formulary updated
2026-01-15 Aetna BMI threshold raised to 35 on /compliance page
2026-02-10 4 of 5 major plans now have PA — industry trend confirmed

2Payer Strategy Intelligence

AI agent monitors health plan corporate communications, investor presentations, leadership changes, and strategic initiative announcements to anticipate payer strategy shifts and contracting opportunities.

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Analyze Payer Corporate Strategy
/investors/press/leadership/blogOpenPageRank
PAYER STRATEGY ANALYSIS — TOP 10 PLANS ════════════════════════════════════════════════════════════ cigna.com /investors: VBC revenue target: 60% by 2028 (currently 42%) /press: $3.8B acquisition of home health company /leadership: New Chief Medical Officer from value-based background /blog: CEO commentary on total cost of care models humana.com /investors: Medicare Advantage star ratings declined — 2 plans dropped /press: Exploring strategic alternatives — potential divestiture /leadership: CFO departure — successor search underway /careers: Hiring freeze across corporate functions
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Generate Payer Strategy Report

Payer Strategy Intelligence — Q1 2026

KEY STRATEGIC SHIFTS ──────────────────────────────────────── 1. Cigna doubling down on VBC — CMO hire + acquisition signal commitment 2. Humana instability — star rating decline + strategic review = uncertainty 3. UHC vertical integration accelerating — Optum expansion continues 4. Anthem rebranding to Elevance completing — new contracting framework CONTRACTING IMPLICATIONS Cigna: VBC contract opportunity — align with new CMO's value agenda Humana: Delay major contracts — strategic direction uncertain UHC: Prepare for Optum pharmacy integration requirements Elevance: Rebrand creates window for relationship reset

3Prior Authorization Policy Tracking

AI agent monitors health plan clinical policy pages to detect PA requirement changes, step therapy updates, and medical necessity criteria modifications that impact patient access and provider administrative burden.

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Detect PA Policy Changes
/docs/compliance/productsPersonas
PRIOR AUTHORIZATION POLICY TRACKER ════════════════════════════════════════════════════════════ POLICIES MONITORED: 4,200 across 347 plans CHANGES DETECTED: 156 in last 30 days NEW PA REQUIREMENTS: Specialty biologics: 23 new PA requirements added Gene therapies: 8 plans added step therapy Oncology combinations: 12 plans added clinical criteria PA REMOVALS (regulatory compliance): Emergency services: 14 plans removed PA per state law Behavioral health: 8 plans reduced PA per federal mandate Preventive care: 4 plans expanded PA-free access
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Assess Administrative Burden
PA Signal
Specialty Drug PA Surge — 23 new PA requirements for specialty biologics across major plans. Average PA approval time: 14 days (up from 8 days in 2025). Domain analysis shows /docs pages with increasingly complex clinical criteria. Provider administrative burden estimated at $34/PA transaction.
INCREASING — PA complexity and volume rising across specialty drugs

4PBM Consolidation Intelligence

AI agent tracks PBM market consolidation, vertical integration moves, and competitive dynamics by monitoring PBM corporate websites, investor communications, and pharmacy network changes.

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Monitor PBM Market Activity
/investors/press/products/partnersOpenPageRank
PBM MARKET INTELLIGENCE — Q1 2026 ════════════════════════════════════════════════════════════ cvshealth.com /investors: Caremark managing 110M covered lives /press: FTC scrutiny of vertical integration model /products: Transparent pricing model launched for new clients express-scripts.com /products: Specialty pharmacy exclusive network narrowed /press: Lost 2 major employer group contracts /partners: 3 specialty pharmacy partners removed from network optumrx.com /products: Mark Cuban Cost Plus integration announced /press: 47M covered lives — record growth /careers: 214 new roles in specialty pharmacy division
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Assess PBM Strategy Impact
Market Signal
PBM Transparency Pressure — CVS transparent pricing launch + Express Scripts client losses + FTC scrutiny signals industry inflection point. Domain analysis shows 3 new transparent PBM domains (age <2 years) gaining traction. Traditional PBM rebate models under pressure — prepare for contract restructuring.
SHIFTING — PBM market dynamics changing rapidly

5Medicare Advantage Expansion Tracking

AI agent monitors Medicare Advantage plan websites for benefit enhancements, geographic expansion, star rating changes, and supplemental benefit additions that signal competitive positioning shifts.

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Track MA Plan Benefit Changes
/products/press/about/complianceCountries
MEDICARE ADVANTAGE EXPANSION SCAN — 2026 ════════════════════════════════════════════════════════════ uhcmedicaresolutions.com /products: 12 new counties added for 2026 plan year /press: Supplemental dental/vision benefits expanded /about: 31M MA members — largest plan humana.com/medicare /products: 3 county withdrawals in Q4 2025 /compliance: Star rating decline to 3.5 — bonus payment at risk /press: Benefit reductions for 2026 plan year devoted.com (Domain Age: 2,847 days) /products: Expanded to 14 new states — aggressive growth /press: Series F funding — $1.2B raised total /careers: 287 new roles — scaling rapidly
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Generate MA Market Report

Medicare Advantage Market Intelligence

MA MARKET DYNAMICS ──────────────────────────────────────── Plans tracked: 847 | Geographic expansions: 34 | Contractions: 12 New entrants: 8 (domain age <3 years) | Star rating changes: 67 KEY TRENDS 1. UHC continuing geographic dominance — 12 new counties 2. Humana contraction signals potential acquisition target 3. Devoted Health rapid expansion — disruptive MA-only model 4. Star rating pressure — 34% of plans dropped a star level 5. Supplemental benefits becoming key differentiator for enrollment

6Medicaid Managed Care Analysis

AI agent monitors state Medicaid agency and managed care organization websites for RFP announcements, contract awards, benefit changes, and population health management requirements across Medicaid programs.

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Track Medicaid MCO Activity
/products/press/docs/complianceCountries
MEDICAID MANAGED CARE INTELLIGENCE ════════════════════════════════════════════════════════════ medicaid.gov /docs: New managed care final rule — rate setting changes /press: Medicaid redetermination updates — enrollment shifts centene.com /products: Won 3 new state Medicaid contracts /press: 27M Medicaid managed care members /investors: Medical loss ratio increasing — margin pressure molina.com /products: Expanded into 2 new state markets /press: Medicaid redetermination net positive — retained 89% /compliance: NCQA health plan accreditation renewed
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Assess Market Opportunities
Medicaid Signal
Post-Redetermination Landscape — Medicaid managed care enrollment stabilizing after redetermination. Centene margin pressure creates potential for contract renegotiation. 4 state RFPs open for 2027 contract cycle. Domain monitoring detected 3 new Medicaid MCO entrants (domain age <2 years) with disruptive technology-first models.
SHIFTING — Post-redetermination market recalibrating

7Employer Benefit Trend Detection

AI agent monitors employer benefits platforms, health plan broker websites, and employee benefits consulting domains to track employer-sponsored health benefit trends, coverage changes, and cost management strategies.

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Scan Employer Benefit Platforms
/products/blog/press/eventsPersonas
EMPLOYER BENEFIT TRENDS — 2026 ════════════════════════════════════════════════════════════ mercer.com /blog: 2026 employer health cost trend: +7.2% projected /products: GLP-1 weight management coverage toolkit launched /events: Employer benefits symposium — March 2026 businessgrouphealth.org /press: 42% of employers adding GLP-1 coverage restrictions /docs: Navigation benefit adoption guide published /blog: Mental health parity enforcement increasing EMERGING TRENDS: GLP-1 management: 78% of employers concerned about cost impact Mental health: 92% expanding behavioral health benefits Navigation services: 34% adopting health navigation platforms Gene therapy: 12% exploring coverage frameworks
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Generate Benefit Trend Report

Employer Benefit Intelligence

2026 EMPLOYER BENEFIT LANDSCAPE ──────────────────────────────────────── Employer domains monitored: 1,240 | Consulting firm domains: 89 Average cost trend: +7.2% | Top concern: GLP-1 cost management STRATEGIC IMPLICATIONS 1. Develop GLP-1 cost management solution for employer clients 2. Expand behavioral health network — employer demand surging 3. Partner with navigation platforms — 34% adoption growing 4. Prepare gene therapy coverage frameworks proactively 5. Position value-based outcomes for employer plan negotiations

8Reimbursement Landscape Analysis

AI agent monitors CMS, state Medicaid, and commercial payer websites for reimbursement rate changes, coding updates, and payment model transitions that impact provider revenue and care delivery economics.

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Track Reimbursement Rate Changes
/docs/press/complianceCountries
REIMBURSEMENT RATE TRACKING — 2026 ════════════════════════════════════════════════════════════ cms.gov /docs: Medicare physician fee schedule — 2.8% conversion factor cut /press: APM performance pathway bonus payments announced /compliance: New MIPS quality measures for 2026 reporting year medicaid.gov /docs: Medicaid DSH payment methodology updated /press: 4 states reducing specialty care rates by 3-8% COMMERCIAL PAYER RATE TRENDS: Average rate increase: +3.4% (CY 2026) Specialty care: +1.8% — below cost inflation Primary care VBC: +6.2% — premium for value-based
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Assess Revenue Impact
Reimbursement Signal
Specialty Care Rate Pressure — Medicare fee schedule cut (-2.8%) combined with commercial rates below cost inflation (+1.8% vs. 4.1% cost growth) creates margin squeeze for specialty providers. VBC premium (+6.2%) incentivizes transition. Domain analysis shows 23% of specialty practices adding /products pages for VBC programs.
PRESSURE — Specialty care margins declining without VBC transition

9Payer Digital Transformation Tracking

AI agent monitors health plan technology investments, digital member experience platforms, AI deployment announcements, and insurtech partnership signals to assess payer digital maturity and identify collaboration opportunities.

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Scan Payer Technology Investments
/products/press/partners/careersIAB Categories
PAYER DIGITAL TRANSFORMATION SCAN ════════════════════════════════════════════════════════════ anthem.com /products: AI-powered claims adjudication launched /partners: Palantir partnership for population health analytics /careers: 142 data science/AI roles posted /press: $1.5B digital transformation investment announced oscarhealth.com (Domain Age: 4,380 days) /products: Full-stack technology platform for health plans /press: Licensing tech platform to traditional plans /api: Open API for provider integration /blog: CTO commentary on AI claims processing
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Assess Digital Maturity Landscape

Payer Digital Maturity Report

DIGITAL MATURITY TIERS ──────────────────────────────────────── Leaders: Oscar, Anthem/Elevance, UHC/Optum — Full AI + digital member Middle: Cigna, Humana, BCBS plans — Partial digital, investing Laggards: Regional plans, small Medicaid MCOs — Legacy systems COLLABORATION OPPORTUNITIES 1. Partner with Oscar for technology platform licensing 2. Integrate with Anthem AI claims for faster adjudication 3. Support middle-tier digital transformation with provider tech 4. Address interoperability gaps between payer and provider systems

10Health Insurance Exchange Monitoring

AI agent monitors ACA marketplace, state exchange, and health plan websites to track enrollment trends, plan design changes, premium adjustments, and market share shifts across individual and small group markets.

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Track Exchange Market Activity
/products/press/pricing/aboutCountries
ACA MARKETPLACE INTELLIGENCE — 2026 ════════════════════════════════════════════════════════════ healthcare.gov /press: Record ACA enrollment — 21.3M for plan year 2026 /products: Enhanced subsidies extended — plan affordability improved oscarhealthinsurance.com /pricing: Lowest-cost silver plan in 14 markets /products: Expanded to 22 states — from 18 in 2025 centene.com/marketplace /products: Ambetter plans available in 28 states /press: Premium increases averaging 8.4% for 2026 /about: Largest ACA marketplace insurer — 4.2M lives
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Generate Exchange Market Report

Exchange Market Intelligence

ACA MARKETPLACE TRENDS ──────────────────────────────────────── Total ACA enrollment: 21.3M | New entrant plans: 14 domains detected Average premium increase: 6.8% | Subsidy impact: 89% receive assistance MARKET SHARE SHIFTS 1. Centene/Ambetter dominates with 4.2M lives — low-cost strategy 2. Oscar rapid expansion — tech-first model gaining share 3. Traditional BCBS plans losing share in 8 states 4. 14 new domain registrations suggest additional market entrants 5. Enhanced subsidies at risk of expiration — monitor congressional action
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