Control costs by insourcing medical drug UM

Automate appropriate decisions, strengthen complex clinical reviews, and prepare for CMS-0062 interoperability.

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Delegate Services in a Heartbeat

Medical drug UM is getting more complex. Managing it in-house shouldn’t be.

Rising drug costs, evolving therapies, and fragmented workflows are making prior authorization harder to scale.
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Cohere extends its proven UM solutions—Cohere Intake™, Cohere Decision™, and Cohere Review™—to medical drug UM, helping health plans contain costs with in-house management:

  • Automate appropriate decisions

  • Apply plan-specific policies and strengthen clinical reviews consistently

  • Maintain control over drug utilization

  • Prepare for evolving interoperability requirements

Drive efficiency and savings for medical drugs with proven UM workflows

Medical benefit drug requests require distinct data, policies, and clinical criteria—but health plans shouldn’t need a disconnected operating model to manage them.

Cohere brings intake, decisioning, and clinical review into one workflow across medical drug and medical services, while supporting the distinct requirements of each. Health plans gain a consistent, connected way to manage high-cost provider-administered drugs while supporting medical necessity, dose appropriateness, site of service, specialty distribution, preferred products and biosimilars.

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Intake

Digitize prior authorization requests across channels, check administrative requirements, and prompt for missing information before submission.
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Decision

Apply plan-specific policies and drug criteria to automate appropriate prior authorization decisions and prepare the rest for human clinical review.
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Review

Use clinical AI to analyze records, surface relevant evidence, and bring applicable guidelines directly into the reviewer workflow.
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Explore the Cohere Unify Platform

Connected Clinical Intelligence Across Your Health Plan

Medical drug UM runs on Cohere Unify, the same clinical intelligence platform that supports workflows across the health plan, from prior authorization to payment integrity. Insights from one area inform the next, so teams work from a shared view instead of disconnected systems.

Explore the Cohere Unify Platform

Overview

Physician expertise drives the AI—not the other way around

Cohere’s physicians and clinical experts shape the AI that supports medical drug UM. We don’t add a generic large language model to a legacy PA process.

AI handles the search, synthesis, and repetitive work. Clinicians remain in control of decisions requiring clinical judgment. And because Cohere operates as a platform within your organization—not a delegated service outside it—your clinicians work with the AI directly, applying your policies and criteria in real time.

Clinical intelligence

Surface the evidence and member context relevant to each request

Policy-grounded review

Apply plan-specific policies and drug criteria consistently

Human oversight

Give clinicians and PharmDs transparent support and control over final decisions

Insource Medical Drug UM. Keep Control.

Health plans managing medical drug UM often face a tradeoff: delegate to an outside vendor and lose control, or build internally and absorb the complexity alone.
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Cohere offers another path. Our in-house platform model brings the clinical intelligence, workflow, and AI into your operations. Your clinical team applies your criteria and makes the calls.
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With that control, health plans can do more than process requests faster, and act on priorities like:

Encouraging preferred drug use

Supporting biosimilar adoption

Optimizing site of care

Applying new-start and continuation criteria consistently

Improving visibility into medical drug utilization and cost trends

Connecting medical drug decisions to the broader care journey

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Prepare for What's next

The future of medical drug prior authorization

The proposed CMS-0062 rule expands electronic prior authorization and interoperability expectations to drugs covered under medical and pharmacy benefits. Cohere’s initial launch focuses on helping health plans prepare for the proposed medical benefit drug requirements.

Cohere has already built and operationalized interoperability infrastructure for CMS-0057. We've built on that foundation to help health plans prepare for:

  • FHIR-based medical benefit drug workflows
  • More consistent electronic information exchange
  • Digital clinical documentation submission
  • Clearer documentation and decision rationale
Isometric illustration of a clipboard with colorful strategy icons—arrows, crosses, and dots—symbolizing personalized healthcare workflows, guided decision-making, and smarter prior authorization processes.
Graphic showing two arrows forming a heart shape at their intersection, with text boxes around it highlighting features: Connected medical drug UM workflows, Clinical-grade AI decisioning, One place for providers, Ready for CMS-0062.
Graphic showing two arrows forming a heart shape at their intersection, with text boxes around it highlighting features: Connected medical drug UM workflows, Clinical-grade AI decisioning, One place for providers, Ready for CMS-0062.Graphic showing two arrows forming a heart shape at their intersection, with text boxes around it highlighting features: Connected medical drug UM workflows, Clinical-grade AI decisioning, One place for providers, Ready for CMS-0062.

Bring **greater intelligence** to medical drug UM

Bring specialty, high-cost, and provider-administered drug prior authorization into a connected, clinically intelligent UM workflow—powered by Cohere, controlled by your team.

Talk with an expert
Talk with an expert

Smarter drug utilization management starts with the right questions

Explore answers to common questions about how Cohere's drug utilization management solution help health plans manage costs, support appropriate prescribing, and keep care on track for members.

Is this a new Cohere product?

No. Cohere is extending its existing Intake, Decision, and Review solutions to support drug UM across medical benefits. These solutions operate on Cohere Unify, Cohere’s clinical intelligence platform.

What types of drug authorization does Cohere support?

Cohere supports specialty, high-cost, and provider-administered drugs covered under the medical benefit.

Will Cohere support pharmacy drug benefit workflows?

Cohere’s initial launch focuses on drugs covered under the medical benefit where we see the most immediate need among our health plan partners. Pharmacy benefit drug support remains part of Cohere’s longer-term vision, and we will share more as we define the scope and timing of those capabilities.

Does Cohere replace a health plan’s PBM or claims-processing system?

No. Cohere supports the medical drug authorization workflow—from intake through decisioning and clinical review. It does not replace core pharmacy benefit administration, formulary design, pharmacy-network management, or claims processing.

How does Cohere use AI in drug utilization management

Cohere uses clinical-grade AI to analyze unstructured records, and surface policy-specific evidence during clinical review. AI can automate decisions when requests meet established criteria, while clinicians retain control over cases that require clinical judgment.

How does Cohere create a clearer provider experience?

Working with Cohere for medical drug UM gives providers one place to submit requests, whether for medical services or medical drugs, and regardless of who ultimately reviews them. Cohere's technology also prompts providers in real time for the information needed for an accurate review, before they submit.

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How can Cohere help health plans prepare for CMS-0062?

Cohere builds on its CMS-0057 interoperability experience to prepare for the proposed medical benefit drug requirements outlined in CMS-0062. We will continue evolving these capabilities as CMS finalizes the rule and publishes implementation guidance.