Banjo Health
Prior authorization decision support for health plans and pharmacy benefit managers, the third payer side vendor in this index alongside Cohere Health and Alaffia, and the one weighted toward pharmacy benefit rather than medical. BanjoPA automates the end to end workflow: the CARE engine extracts information from faxed or digital prior authorization requests, validates and maps it to case fields, then matches the case against the payer's own clinical criteria. The distinguishing technical step is that CARE transforms dense clinical guidelines into decision trees, converting narrative coverage policy into an executable structure, and the platform reads prescriber notes directly from the EHR rather than relying on manual data entry or fax and phone follow up. The company states its model matches each request against the specific payer's rules rather than applying generic AI, and that every AI generated recommendation carries detailed evidence and an explanation. BanjoA&G extends the same approach to appeals and grievances. Positioned around CMS-0057-F interoperability and prior authorization compliance. Holds HITRUST r2 certification. Named implementation with Navitus, a large transparent pass through PBM owned by SSM Health and Costco serving over 18 million lives, expanded across employer and health plan lines including Medicare and Medicaid in December 2025. Founded by Saar Mahna.
Capability Axes
The CARE engine does the substantive work: extracting structured facts from faxed and digital requests, reading prescriber notes from the EHR, and converting narrative clinical guidelines into executable decision trees. That guideline to decision tree transformation is the technically interesting step, since coverage policy written as prose is the actual bottleneck in prior authorization automation.
Two stated design choices work in the buyer's favor. Every AI generated recommendation carries detailed evidence and a clear explanation rather than a bare determination, and the company states staff intervention is required for exceptions once criteria are matched, placing humans on the hard cases. Held back from A because, unlike Cohere Health, the company does not publicly state whether automated determinations are limited to approvals. In a pharmacy benefit context that distinction is decisive: an automated denial of a prescribed drug is a materially different act from an automated approval, and a buyer should establish in contracting which the platform is configured to issue.
One substantial named implementation carries most of the weight: Navitus, described as the largest transparent pass through pharmacy benefit manager, owned by SSM Health and Costco and serving more than 18 million lives, expanded the deployment across employer and health plan lines including Medicare and Medicaid in December 2025. An expansion by an existing customer of that scale is stronger evidence than a new logo. Held back from A because turnaround and accuracy improvements appear as customer testimonial rather than measured figures with stated baselines.
HITRUST r2 certification, the risk based two year assessment rather than the lighter e1, which is a substantive certification for a vendor handling prescriber notes and coverage decisions. Held back from A because no public trust center with control detail or audit dates was retrieved.
No public pricing. Contact the vendor. Enterprise agreements with health plans and pharmacy benefit managers. Regulatory deadlines around CMS-0057-F are the stated adoption driver, which means buyers may be negotiating under time pressure; worth establishing whether pricing reflects compliance urgency or steady state operation.
Clearly bounded to payer side utilization management for health plans and pharmacy benefit managers, spanning prior authorization, appeals, grievances, and clinical criteria automation, with a pharmacy benefit emphasis that distinguishes it from the medical benefit focus of others in this lane.
Pricing
Vendor-published figures are labeled as such. Figures labeled “Estimated” are derived from third-party sources and have not been confirmed by the vendor.
| Entry Price | Pricing Basis | BAA Tier | Implementation | Source |
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Contact the vendor
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Enterprise agreements with health plans and PBMs | — | — | Vendor Published |
No rate card published. Enterprise agreements with health plans and pharmacy benefit managers. Note the negotiating context: the company positions heavily around CMS-0057-F compliance deadlines, so buyers may be contracting under regulatory time pressure. Worth separating what is required for compliance from what is being sold as capability, and establishing whether pricing reflects a deadline driven implementation or ongoing operation.