12+ specialized AI agents,
purpose-built for PBM.
Every agent is designed for a specific PBM workflow. They collaborate through our Triage orchestrator to deliver cited, accurate answers from your own documents and live data sources.
12+ specialized agents,
organized by tier.
Core agents power every deployment. Built-in agents activate automatically. Optional agents enable per-customer based on needs.
Triage Agent
CoreAnalyzes every question to understand intent, then routes to the right specialist. Handles general questions directly. Orchestrates multi-agent fan-out for complex queries.
Document Intelligence
CoreSearches uploaded formularies, clinical policies, and PA criteria using hybrid semantic + full-text search. Every answer includes inline citations with exact page numbers.
General Knowledge
CoreAnswers general PBM questions without requiring uploaded documents. Draws on industry expertise for conversational assistance and quick lookups.
Prior Authorization
Built-inChecks PA requirements, step therapy protocols, quantity limits, and day supply restrictions for any drug. Billy's #1 priority — the most impactful agent for clinical teams.
Formulary Lookup
Built-inInstant tier status, coverage determinations, preferred/non-preferred classifications, and restriction details. Structured lookups with generic equivalent suggestions.
Drug Information
Built-inComprehensive drug data from public APIs: labels, interactions, safety alerts, recalls, biosimilar lookups, NDC crosswalks, and adverse event reports.
Drug Pricing
Built-inNADAC acquisition costs, AWP/WAC comparisons, generic alternative pricing, and patient cost estimation. Real-time data from CMS pricing feeds.
Claims Analytics
OptionalGenerates utilization reports, spend summaries, and trending analysis. Connects to your claims data warehouse for custom analytics queries.
Data Transformation
OptionalParses eligibility files, claims data, formulary uploads, and rebate reports. Automates field mapping and format conversion between PBM systems.
Regulatory & Compliance
OptionalTracks CMS Part D rules, state PBM laws, and upcoming regulatory changes. Monitors the Federal Register for proposed and final rules affecting PBM operations.
Industry Monitor
OptionalProactive intelligence from FDA announcements, PBM industry news, drug approvals, and regulatory changes. Surfaces what matters before you have to search for it.
Clinical Programs
OptionalDUR screening, medication therapy management, adherence monitoring, opioid management, and REMS compliance. The clinical backbone for patient safety workflows.
Connected to the data
your agents need.
MCP (Model Context Protocol) servers bridge real-world pharmaceutical data into the AI. Agents call these tools automatically — no manual lookups required.
openFDA
Free APIDrug labels, adverse events, recalls, Orange Book patents and exclusivity data.
RxNorm
Free APIDrug name normalization, NDC crosswalks, therapeutic classifications, and interaction checking.
DailyMed
Free APIFDA-approved drug labeling (SPL), prescribing information, and medication guides.
NADAC
Free APIWeekly pharmacy acquisition costs from CMS. The benchmark for real-time generic pricing.
Federal Register
Free APIProposed and final rules from CMS, FDA, and HHS. Monitors regulatory changes affecting PBM.
ClinicalTrials.gov
Free APIPipeline drugs, ongoing trials, and new indications. Stay ahead of formulary planning cycles.
The right model for
every task.
Not locked into one AI provider. Claimalytics selects the optimal model for each operation — fast models for routing, powerful models for complex reasoning.
| Model | Used For | Speed |
|---|---|---|
| GPT-4o-mini | Triage routing, structured lookups, general knowledge | Fast |
| GPT-4.1-mini | Prior authorization reasoning, complex analysis | Fast |
| GPT-4o | Document analysis, multi-step synthesis | Moderate |
| User-Selected | Document Intelligence (configurable per tenant) | Varies |
Every answer comes with
a paper trail.
Claimalytics doesn't guess — it searches, finds, and cites. Every response traces back to the exact document, page, and passage.
Inline Citations
Citations appear as clickable tags within the response text. Each links to the source document and page number.
Source Verification
Click any citation to see the original passage highlighted in context. Verify the AI's interpretation against the source material.
Multi-Source Synthesis
Complex questions pull from multiple documents. See which sources contributed to each part of the answer.
No Hallucinations
Grounded in your documents and verified data sources. If the answer isn't in the data, the system tells you — it doesn't make it up.
Three steps to
smarter PBM operations.
Upload Your Documents
Upload your formulary, clinical policies, and PA criteria. Our AI extracts and indexes every page in minutes.
Ask Anything
Ask in plain English: "What are the PA requirements for Humira?" or "Compare Tier 1 diabetes medications."
Get Cited Answers Instantly
Every answer traces back to your source documents. Click any citation to verify. No hallucinations, no guesswork.
Ready to see the platform in action?
We'll walk you through a live demo with your own documents.