01 / The central argument
We already have the data.
Here is what it lets us sell.
CMS Intelligence Engine · Internal pitch · October 2026
The commercial value is not the warehouse. It is the analysis, judgment and client decisions the warehouse makes possible.
02 / The opportunity
Clients buy answers.
Not infrastructure.
The business model combines public CMS evidence with specialized market access expertise.
Spending, plans, utilization, providers, access and reimbursement.
Join and interpret multiple data sources instead of isolated lookups.
Explain limitations, implications and practical options.
Inform competitive strategy, market access, billing or outreach.
The deck references Avalere as a business-model comparison, not a claim of comparable data or service capabilities.
03 / Existing resources
What we already have
Downloaded CMS public use files, organized across major Medicare market-access domains.
| Data resource | History represented in deck |
|---|---|
| Billing and coding | Current HCPCS, ICD-10, CPT references; HCPCS files 2017–2026 |
| Drug spending / utilization | Annual 2017–2024; preliminary Part B quarterly 2025–Q1 2026 |
| Payment limits / ASP | Quarterly 2017–Q4 2026 |
| Plans and enrollment | Landscape 2025–2027; benefits 2019–2026; enrollment through Sep 2026 |
| Formulary / UM | January 2019–September 2026 |
| Provider activity | Part D and Part B 2017–2024; hospital outpatient 2019–2024 |
| Pharmacy networks | Plan network files for held formulary years |
| Plan/parent/county crosswalks | 2026–2027 with county reference data |
04 / Five consulting capabilities
Five questions our clients ask
What's changing in my therapeutic market, and how should I respond?
How is my therapy coded, covered and paid?
Where is my therapy available, and what restrictions apply?
Which clinicians and geographies drive observable use?
How do competitive and policy changes affect positioning?
05 / Market & competitive intelligence
The retinal market is shifting
Share of reported claims among four named anti-VEGF products, not the entire anti-VEGF market.
Eylea 2 mg + Eylea HD combined share
Pavblu share change
06 / Coding & reimbursement
From codes to a client deliverable
Example: Lembaz (adrabetadex) billing and coding guide for Beren — already delivered by the team.
Niemann-Pick disease type C.
Potential unclassified/miscellaneous product codes depend on payer and site; NDC on claims.
Candidate codes for intrathecal administration, requiring service-specific review.
Sample UB-04 and CMS-1500 claims, coding considerations and tracking guidance.
07 / Payer, coverage & access
Formulary listing is not unrestricted access
Medicare Part D access for oral CGRP migraine products, January 2024 to September 2026.
Qulipta listing increase since January 2024
PA among listed plans for all three, approximately
| Product | Jan 2024 listed | Sep 2026 MA-PD | Sep 2026 PDP | PA among listed |
|---|---|---|---|---|
| Qulipta | 24.4% | 74.7% | 49.9% | 97.0% |
| Nurtec | 81.1% | 81.4% | 72.2% | 97.2% |
| Ubrelvy | 41.9% | 81.7% | 49.9% | 97.0% |
08 / Provider & geographic intelligence
Finding clinicians one step from the patient
2024 Medicare Part D prescribers for a urea cycle disorder therapy basket; an investigative starting point for ARG1-D targeting.
Unique NPIs
Published claims
States represented
09 / Commercial strategy
A concentrated SGLT2 market
2024 Medicare Part D gross spending combined with a separate September 2026 formulary-access snapshot.
2024 gross Part D class spending
Class gross spending attributed to Jardiance + Farxiga brands
10 / The business decision
Use what already exists
Start with a live client need rather than a hypothetical use case.
Identify precisely what question the analysis helps answer.
Bring an existing analysis or deliverable into the client conversation.