It's the chart, not the cost
Specialty drugs are three percent of scripts and half of spend. Each prior auth is a chart-read inside a guideline inside a formulary inside a benefit. Owl reads every page on arrival, walks the formulary and the NCCN, FDA and compendium support, and turns the pend into a determination on first touch.
+20 pts
GLP-1 share of specialty spend
64%
Specialty PAs auto-approvable
$11.40 → $1.80
Cost per PA touch
Three AI agents on a Rx PA. Reading. Cross-referencing. Answering.
One PA: a CPT-J9035 oncology authorization with off-label support.
Anonymized composite. Member 51F with HER2-negative metastatic breast cancer, prescriber requesting bevacizumab off-label.
External data only. None of this lives in your CMS. Owl gathered it from public records, professional networks, registries and the open web, then resolved it to this claimant.
NCCN Breast v3.2025 supports bevacizumab in HER2-negative metastatic breast cancer at Category 2A. Plan medical policy 9.22 explicitly covers oncology drugs with NCCN ≥ 2A support. The off-label flag clears on coverage grounds.
Cross-PBM pharmacy claims via Surescripts confirm two prior systemic therapies (paclitaxel + capecitabine), so step requirements are satisfied. No need to pend for prescriber attestation.
Oncologist NPI clean on OIG LEIE, SAM.gov exclusion, DEA action database, and state medical board. No prior fraud referral or quantity-limit override pattern across the Owl cross-payer graph.
Owl IRO corpus (n=180K) shows denials of NCCN Cat 2A oncology drugs in metastatic settings overturn at 78% on external review, often with public CMS Stars exposure. There is no defensible policy basis for denial here.
Yes. Plan medical policy 9.22 covers oncology drug uses with NCCN compendium support at Category 2A or higher. NCCN Breast v3.2025 supports bevacizumab for HER2-negative metastatic breast cancer at Category 2A. The member’s diagnosis matches. Two prior lines of therapy are documented in Surescripts cross-PBM history, satisfying step requirements. Approve.
Pre-stage step-therapy documentation for pertuzumab and trastuzumab-deruxtecan, both of which have NCCN support in adjacent settings and are common next-line requests. The member has no prior fill history for these per Surescripts. Standard step-therapy language attached.
What the world says about your Pharmacy & PBM claimants, none of which lives in your CMS.
Internal claim data is half the picture: it tells you what the claimant told you. OwlSignal continuously gathers external data (public records, professional and corporate registries, court dockets, social and open web) and matches it back to the claimant. These are the families that move the needle on Pharmacy & PBM.
NCCN, AHFS DI, Lexi-Drugs, Clinical Pharmacology, Micromedex DrugDex, FDA labels and FDA REMS: the compendium support that determines off-label coverage and step-therapy waivers.
Surescripts, RxHub and PBM-clearinghouse data: the fill history that lives outside your PBM but supports trial-and-failure step-therapy decisions.
OIG LEIE, SAM.gov exclusion, DEA action database, state medical board sanctions and Owl’s cross-payer prescribing graph, to surface prescriber risk on every PA.
IRO decisions from state DOIs and CMS: what gets overturned on Rx denials, by drug class and by denial reason. Owl’s corpus is 180K decisions.
Formulary tiers, step-therapy schemas, quantity limits, age limits, gender limits, prior-auth criteria, medical policy library: read once, walked on every PA.
OIG annual Workplan, CERT national error data, GLP-1 utilization patterns and the FWA referral defensibility checks that pharmacy SIU teams rely on.
Numbers from health plans and PBMs running Owl on Rx in production.
Built for the regulatory shape of Pharmacy & PBM.
Lives where your Pharmacy & PBM files live.
PBM platforms
CVS Caremark, Express Scripts, OptumRx, Prime, MedImpact
Core admin
HealthEdge HealthRules, Trizetto Facets, QNXT
UM platforms
CoverMyMeds, Surescripts ePA, ZeOmega Jiva
Compendium libraries
NCCN, Micromedex DrugDex, Lexi-Drugs, AHFS DI
Pharmacy networks
Surescripts, RxHub, NCPDP networks
Identity & SSO
Okta, Azure AD, PingFederate, SAML, SCIM
Bring us a month of specialty PAs. We’ll show you the auto-approve rate on day one.
Two-week pilot. Your PA stream, your tenant, your formulary. We measure cycle time, auto-approval rate, IRO survival rate and per-touch cost against your own ground truth.