Case Study
Commercial Health Plan
GLP-1 Continuation Governance
Client identity redacted. Data is real. Methodology published.
Cohort 1 · CGS v1.1 · 90-day governance cycle
The Challenge
No one was watching after authorization.
A large commercial health plan with 25,000+ specialty pharmacy members on GLP-1 agonists had no structured governance for therapy continuation post-authorization. Prescriptions were approved once and refilled indefinitely. No review cadence existed.
- Annual specialty pharmacy spend growing 15%+ year-over-year
- No visibility into whether continuation was clinically appropriate
- No documentation trail for governance decisions at the population level
- Stop-loss carrier raising questions about governance during renewal
25K
Specialty pharmacy members on GLP-1 agonists
15%+
Annual specialty spend growth, ungoverned
0
Structured continuation reviews per year
The Approach
Structured governance. Zero clinical authority.
Cadence deployed a 90-day governance cycle using CGS v1.1, applying seven trigger categories to the full continuation cohort. The engagement was advisory only. No prescriptions were changed. No prior authorizations were denied. The output was governance documentation, not clinical intervention.
Governance Standard
CGS v1.1
7 trigger categories: DUR12, DOSE, LABGAP, COMORBID, NOOUT, BIOSIM, PA_BLIND
Cycle Length
90 Days
Full population screen, flag, review, and certification within a single quarter
Review Model
Independent PharmD Reviewers
Not plan employees. No duty-to-act conflict. Advisory capacity only.
Possible Outcomes
Continue · Adjust · Taper · Switch
Every reviewed member receives exactly one documented outcome. No ambiguity.
The Results
$8.6M governance signal value. First cycle.
Of 25,000 members assessed, 6,250 triggered at least one governance flag. 5,750 completed independent PharmD review. 60% of reviewed members had their governance trajectory changed. 40% were confirmed appropriate and documented as such.
5,750
Reviewed (92% completion)
Review Outcomes
60%
Review Influence Rate (RIR)
40%
Documented Appropriateness Rate (DAR)
$8.6M
Governance Signal Value (GSV)
Visual
The governance funnel.
From total population to measured influence. Every step documented.
Influenced = Adjust (1,438) + Taper (1,150) + Switch (862)
Confirmed = Continue, documented as appropriate (DAR)
Cycle 2
50% governance persistence. $15.7M cumulative.
Governance is not a one-time event. Cadence measured whether Cycle 1 influence persisted into Cycle 2. Half of all influenced members maintained their adjusted trajectory. The second cycle generated an additional $7.1M in governance signal value.
| Outcome |
Cycle 1 |
Persisted |
Rate |
| Adjust |
1,438 |
863 |
60% |
| Taper |
1,150 |
518 |
45% |
| Switch |
862 |
345 |
40% |
| Total |
3,450 |
1,726 |
50% |
50%
Governance Persistence Rate (GPR)
$15.7M
Cumulative 2-cycle GSV
The Deliverable
A sealed governance certificate. Not a report.
Every governance cycle produces a versioned, sealed certificate with full audit trail. This is the artifact that changes renewal conversations.
Certificate
Sealed Governance Certificate
Version-controlled, timestamped, with cryptographic fingerprint. Cannot be altered post-seal.
Board Ready
Executive Summary
One-page summary suitable for board presentation and fiduciary documentation.
Audit Trail
Complete Review Record
Every review logged with reviewer credentials, timestamps, trigger categories, and outcome rationale.
Renewal
Stop-Loss Documentation
Formatted for carrier submission. Shows population-level governance where none existed before.
What Made This Different
Governance, not management.
Advisory Only
No fiduciary liability. No prescriptions changed. No prior authorizations denied. Pure governance documentation.
External Reviewers
Independent PharmD reviewers, not plan employees. No duty-to-act conflict. No internal politics.
Population Level
Not individual case management. Population-level governance across 25,000 members with consistent methodology.
Measured Influence
Governance influence rate is measured, not estimated. RIR + DAR = 100%. Every case has exactly one documented outcome.
"We've never been able to show our carrier that we governed continuation at the population level. The certificate changed the renewal conversation."
VP, Pharmacy Benefits