How “Modern” Enterprise Health Technology Allows Health Plans to Excel at Managed Care

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As a health plan in 2026, your goal is to improve overall operating efficiency while maintaining compliance, providing excellent care to patients, and enhancing the member experience. Efficiency isn’t just about speed, but that is often a byproduct of becoming more efficient and improving workflows or streamlining all aspects of a problem to get to multiple solutions. You do end up with a more cost-effective, satisfying solution, faster.

True efficiency allows organizations to be nimble in their benefit designs, build targeted clinical programs, and, importantly, be fiscally responsible while improving member care.

Advancements in Health Tech are Driving Pharmacy Benefit Administration Forward

Modern enterprise health platforms, like Judi®, give health plan leaders direct access into the systems built to provide care to their health plan members. With direct access comes something most health plans don’t have presently – total control over their pharmacy benefit offering. As we’ve seen time and time again on the pharmacy benefit management (PBM) side of the business, working with employers and other plan sponsors to manage their pharmacy benefit platforms more efficiently and transparently, it’s impossible to improve service levels and member care while maintaining cost discipline if you’re reliant on legacy claim adjudication software.

Perfecting the administration of a transparent PBM program and evolving the supporting infrastructure isn’t easy. But through trial and error, we’ve deployed a platform that allows health plans to dive further into their benefits, if they choose to. New features are rolled out regularly, in response to regulatory changes, market developments, and innovation.

Three of those new features that every health plan should have include:

An Intuitive Member Dashboard

The member activity dashboard is designed to bring the most relevant member insights into one place. With a comprehensive view of claims, eligibility, accumulations, and more, users can now access key information without navigating between multiple pages or dozens of unnecessary keystrokes. This feature also allows call center staff to remediate issues quicker, as answers to common questions are at their fingertips.

With pharmacy benefits occurring in real time, this level of review and triaging is vital to ensuring that patients have access to the medication they need at the lowest possible cost, without disruption or significant delay.

A Test Adjudication Module

Testing claims has never been seamless, until now. Judi’s test adjudication module tools create test members, simulate real pharmacy transmissions, and uncover detailed claim insights. It’s faster, more intuitive, and built to ensure accuracy at every step of the process. Systems of the past conduct their testing in “lower” environments – never truly testing a benefit, a benefit design change, or a formulary update in the actual production system the claim will adjudicate in. Inevitably, this leads to breaks when deployment occurs. With Judi, health plans can be confident when an update is made that the system will treat the prescription as a real claim – ensuring that every piece of the benefit design is addressed.

The best part? This allows for a testing cycle that is fully transparent from the adjudication system to the health plan’s own analysts.

Artificial Intelligence (AI) in Prior Authorizations

What we are calling “AI System Assist” in our prior authorization (PA) tool is changing the game. By matching 84% of faxes with 99% accuracy, it’s cutting down manual work and speeding up urgent cases when it matters most.

Leveraging the enhancements AI can bring to the table is crucial in any PBM’s roadmap. Our strict corporate governance sets rules around AI’s use, and we’re deploying it in instances where there’s a clear operational efficiency benefit. While AI does not replace a clinician’s review or approval of a PA, it allows our clinical teams to focus on the member and their care while the administrative work of completing the forms is aided by AI. The result is less friction and better support for our health plan partner and their plan members.

It's Time to Stop Accepting the Status Quo

If you are a health plan executive and have faced another year of rising costs, intensifying competition, or long lead times for customizations or system enhancements, it’s time to evolve with the market. With a more modern tech stack, the gains from efficiency can be redeployed to improve what matters most, managing care for people – your plan members.