Live · 24/7 claims surveillance

Every prescription,
reviewed in seconds,
not once a day.

24/7 prescription claims surveillance that retires the manual daily drug review queue. Pharosa continuously streams adjudications from your pharmacy networks, layers clinical rules and large-language-model reasoning, and auto-resolves the routable cases — so your clinical team only sees the ambiguous ones.

Request a demoSee the workflow
Built for post-2024 PBM transparency auditsRules-first; AI only on ambiguous cases
Live surveillance
today · all networks
2,184 claims1,961 auto-resolved81 routed for review
ClaimTriggerDecision
Eliquis 5mgM-44192DDI — warfarinReviewer
Metformin 1000mgM-44903Dose above maxAuto resolve
Atorvastatin 40mgM-45015Duplicate therapyAuto resolve
Humira 40mgM-44221Missing PA docRoute PA
Lisinopril 20mgM-45082DDI — potassiumAuto resolve
Ozempic 0.5mgM-44861Off-label doseReviewer
Watching 12 pharmacy networks · last 30 seconds shown
Built forHealth plansThird-party administratorsSelf-funded employersPayers migrating off legacy PBM rails

The platform

Built around one premise:
every claim, every minute.

The Daily Drug Review queue exists because legacy adjudication runs once a day. Pharosa closes that loop, and folds the four categories of clinical review that block the queue into one continuous decision stream.

See how it works
Drug-drug interactions
Detects pairwise and cascade interactions against an up-to-date compendium; surfaces only the combinations a clinician would pause on, ranked by severity.
Dose range errors
Daily-max, weight-banded pediatric caps, renal-adjusted ceilings. Anything outside the window pages the reviewer with the rule that fired and the override path.
Duplicate therapy
Same-class, same-mechanism, and combined-fill detection. Pulls the member run sheet so the reviewer sees the prior ninety days, not just the claim in front of them.
PA documentation
Matches the claim to the plan’s PA matrix, flags missing or stale clinical, and assembles the packet a reviewer would otherwise build by hand.

The workflow

Stream. Reason. Resolve. Audit.

Pharosa layers clinical rules and large-language-model reasoning over every adjudication — auto-resolves the routable cases, routes the ambiguous ones through a structured handoff, and audits the decision on the way out.

01

Stream

Every adjudication arrives in seconds, not the next-morning batch. Ingestion is normalized against the pharmacy network’s schema so downstream rules don’t care which network sent it.

hands off to reason
02

Reason

Clinical rules layer first; an LLM adjudicator steps in for ambiguous cases (off-label regimens, partial fills, prescriber context). The AI never sees the rules as optional.

hands off to resolve or route
03

Resolve or route

Routable, low-risk cases auto-resolve through your existing edits, with a paper trail. Ambiguous ones forward to a human reviewer through a structured handoff — context, rule fired, and recommended action attached.

hands off to audit
04

Audit

Every decision logs the data, the rule, the model output, and the override, so compliance can answer a state PBM-transparency audit without a manual re-run.

audit-ready on every claim

What replaces for whom

Built for teams squeezed between Big 3 PBM marginsand a patchwork of single-purpose tools.

Clinical-ops leaders
Stop staffing the daily drug review desk. The end of the morning queue of three thousand claims in a spreadsheet.
Compliance officers
Pre-built for post-2024 PBM transparency laws. The audit log writes itself.
Payers migrating off legacy PBM rails
A cloud-native stack that splits cleanly from Big 3 PBM margins without inheriting their stack.
Self-funded employers & TPAs
A clinical-operations layer that bolts onto the benefit-verification and PA tools already in place.

Why now

The procurement short-list
has changed.

Post-2024 PBM transparency laws, FTC scrutiny of rebate spreads, and the valuation benchmark set by Judi Health have moved AI-native PBMs from curiosity to a category buyers actively evaluate.

  1. 01
    2024+PBM transparency laws in force across the largest states.
  2. 02
    FTCActive scrutiny of spread pricing and rebate structures.
  3. 03
    ValuationJudi Health has reset the procurement benchmark for AI-native PBMs.

FAQ

The questions we hear first.

Pharosa is led by a clinical reviewer who worked the DDR queue inside a major insurer. These are the questions that came back from clinical-ops and compliance the first time around.

Most point tools (Ushur, Banjo Health, Infinitus, Cohere) solve one part of the workflow — PA intake, benefit checks, fax automation. Pharosa replaces the upstream Daily Drug Review queue itself, then routes the cases those tools already handle into them with full clinical context.

Live · 24/7 claims surveillance

Retire the daily drug review queue.

We work with a small group of health plans, TPAs, and self-funded employers in parallel onboardings. Tell us about your adjudication volume and the clinical rules that fire most often — we’ll come back with a deployment plan.

A clinical reviewer reads every inbound.
What to bring
Three things help us come back with a useful reply.
1Claim volume per day, by network
2The two clinical rules that fire most often
3Where the human review queue sits today