Medicare Market Intelligence combines 100% unsampled CMS claims data with Milliman's actuarial expertise to deliver real-time Medicare market intelligence.

Your critical questions, answered

Select your business to see how Medicare Market Intelligence’s specialized modules solve your most pressing business challenges and inform strategic decisions

Plan sponsors

Pharmacy groups

PBMs

Life Sciences

Plan sponsors

For Part D plans and Medicare Advantage organizations

How do my pharmacy network reimbursement rates compare to market benchmarks across different pharmacy types and drug categories?

Module: Pharmacy Network Discounts

Benchmark reimbursement rates against competitors
Negotiate better pharmacy network contracts

Are emerging pharmacy utilization trends specific to my plan or reflective of broader market dynamics?

Module: Emerging Part D Claims

Identify trends and benchmark utilization patterns
Distinguish plan-specific trends from market-wide shifts
Optimize pharmacy coordination and inform formulary and benefit design

How do my medical costs and utilization patterns compare to competitors and traditional Medicare across service categories?

Module: Emerging medical benefit claims

Analyze medical utilization trends across Parts A, B, and C
Benchmark medical utilization by condition and plan sponsor

Which members am I gaining, retaining, or losing — what is their risk profile, and what’s driving enrollment changes in my market?

Module: Member Migration

Track member movement patterns and risk profiles
Understand retention drivers and competitive dynamics to reduce churn
Gain early insight into spend patterns of joiners

Which specific prescribers or pharmacies are contributing to adherence gaps that impact my Star ratings?

Module: Adherence

Improve Star Ratings through targeted interventions
Identify prescriber- and pharmacy-level opportunities

How do the adherence patterns of members I won during AEP compare to my existing book, and can I intervene before it impacts my Star ratings?

Module: ‘New-to-plan’ adherence

Compare adherence patterns of AEP joiners against retained members
Identify at-risk cohorts 4–5 months before Star ratings are finalized
Deploy targeted interventions on newly-acquired members before gaps compound

Data foundation

The data sources behind Medicare Market Intelligence and how we enrich them

Our platform is built on 100% unsampled data from CMS’s Research Identifiable Files (RIF), with claim- and member-level detail covering the entire Medicare population. Part D prescription drug event (PDE) records and traditional Medicare claim summaries are available with as little as 2 weeks of lag, while Part C encounter data provide comprehensive Medicare Advantage (MA) insights.

Complete claims detail

Every National Drug Code (NDC) with prescriber National Provider Identifier (NPI), pharmacy National Council for Prescription Drug Programs (NCPDP), and dispensing details
Complete member demographics by month: age, geography, low-income subsidy (LIS) status, dual eligibility, and disease indicators
Plan identifiers (contract, plan benefit package), benefit design parameters, and complete financial reconciliation
Hundreds of additional data elements supporting deep analytical needs

Milliman value added analytics

Our actuarial team enriches the raw CMS data with proprietary methodologies and industry-standard benchmarks to deliver actionable intelligence:

Enhancements:

Enhanced entity resolution for PBMs, pharmacy chains, and prescriber networks
Comprehensive drug pricing benchmarks
CMS-compliant risk adjustment scores and disease hierarchies
Imputed medical costs for Part C encounters
CMS Stars measure calculations for adherence and outcomes
Member attribution logic linking patients to pharmacies and providers

Key benefits

Outperform competitors with actuarial-grade benchmarks

Compare your plan performance against every market participant using CMS-compliant risk scores and Milliman's proven methodologies. Make confident strategic decisions backed by 75-plus years of actuarial expertise and complete market data.

Drive significant contract savings with complete market intelligence

Negotiate from a position of strength with comprehensive reimbursement benchmarks across all competitors. Identify opportunities for improved contract terms across pharmacy types, drug categories, and 20-plus dimensions—leading to millions in potential annual savings.

Track every member, every claim—know where they go

Monitor real member migration patterns across the entire Medicare landscape. Quantify financial impact of enrollment changes by analyzing prior-year utilization and cost profiles for every cohort, protecting your high-value membership.

Answer complex questions in minutes, not months

Generate custom reports at any level—national trends to individual pharmacy—using 100% unsampled data, not statistical samples. Transform weeks of manual analysis into minutes of data-driven insights.

Platform capabilities

Interactive dashboards and custom reporting

Explore complete claims data through intuitive dashboards tailored to your role. Generate custom reports filtered by plan sponsor, member cohort, therapeutic class, prescriber network, or any combination of many other available dimensions.

Rebate modeling and scenario analysis

Model rebate structures and formulary positioning scenarios using your actual claims data. Evaluate financial impacts of drug placement decisions with confidence, leveraging both plan-specific and market-wide utilization patterns.

Purpose-built for Medicare stakeholders

Whether you’re a Part D plan sponsor, PBM, retail pharmacy chain, specialty pharmacy, or life sciences company, our modules are designed specifically for your analytical needs and business objectives within the Medicare marketplace.

Analytics Modules

Purpose-built tools for Medicare stakeholders

Pharmacy Network Discounts

Benchmark pharmacy reimbursement rates to drive millions in contract savings

Compare your rates against every competitor PBM and chain using complete Part D data. Analyze by network status, dispensing channel, drug category, and 20+ dimensions to identify immediate savings opportunities and strengthen your negotiating position.

Key insights you’ll gain:

Benchmark by preferred/standard/out-of-network status
Compare across retail, mail order, and specialty channels
Filter by drug attributes, formulary tier, and plan type
Identify rate outliers for immediate contract renegotiation
Track reimbursement trends month-over-month to spot market shifts

Pharmacy market share

Monitor competitive positioning and capture growth opportunities

Track prescription volume trends and market share across pharmacy chains, PBMs, and plan sponsors with complete data. Segment by geography, individual drugs, and channel to identify competitive threats and expansion opportunities.

Key insights you’ll gain:

Track market share trends by pharmacy chain, PBM, and plan sponsor
Segment by LIS enrollment, geography, and drug name
Monitor brand, generic, and specialty channel performance
Identify plan type opportunities
Spot competitive threats before they impact your business

Emerging Part D Claims

Benchmark utilization and spot trends in near-real-time

Identify whether your experience diverges from market norms with near-real-time Part D data. Drill from organization to plan to drug level with comprehensive cost metrics to inform strategic decisions.

Key insights you’ll gain:

Benchmark drug-specific and plan-level utilization against market
Drill from parent organization to individual plan and drug
Access total allowed cost, scripts, member cost-sharing, CGDP/MDP, and other metrics
View results in absolute terms or PMPM basis
Identify emerging trends within 2 weeks of claim adjudication

Medical Claims Experience view from Milliman Medicare Market Intelligence

Emerging medical benefit claims

Optimize MA plan costs with comprehensive encounter data

Analyze medical utilization trends using complete Parts A, B, and C data categorized by Milliman’s Health Cost Guidelines™ (HCG). Benchmark your MA plan against competitors and traditional Medicare to identify significant cost management opportunities.

Key insights you'll gain:

Track spending patterns across all service categories (inpatient, outpatient, professional).
Benchmark medical costs against competitors and traditional Medicare.
Analyze utilization using Milliman’s HCG framework.
Identify cost outliers and management opportunities.
Inform benefit design and provider contracting strategies.

Member Migration

Track member movement and quantify financial impact

Identify which members you gained, retained, or lost — and where they came from or went to. Quantify enrollment changes by analyzing prior-year utilization and cost profiles to protect your high-value member segments.

Key insights you’ll gain::

Track member movement patterns across the entire Medicare landscape
Identify exactly where members came from or went to
Analyze prior-year drug utilization and cost profiles by cohort
Quantify financial impact of enrollment changes
Understand competitor vulnerabilities and protect high-value segments

Adherence

Improve Star ratings with targeted intervention opportunities

Optimize CMS Stars performance with actionable adherence intelligence. Identify intervention opportunities at contract, prescriber, and pharmacy levels using near-real-time data to improve PDC for the three key Stars measures.

Key insights you’ll gain:

Benchmark adherence rates against market leaders
Pinpoint specific prescribers or pharmacies contributing to gaps
Identify intervention opportunities for diabetes, hypertension, and cholesterol meds
Deploy targeted interventions using near-real-time claims data
Track improvement over time to protect and enhance Star ratings

Pharmacy Share of Customer

Maximize prescription capture rates and customer loyalty

Identify which customers fill at your locations and where their remaining scripts go. Benchmark share-of-wallet against competitors to develop targeted strategies that increase loyalty and capture additional prescriptions.

Key insights you'll gain:

See which customers fill prescriptions at your locations
Identify where remaining scripts go to competing pharmacies
Benchmark share-of-wallet by store, market, and drug category
Segment by LIS status, geography, and therapeutic category
Develop targeted strategies to increase customer capture rates

Prescriber targeting

Identify high-potential prescribers and quantify the targetable opportunity for any drug or class

Pinpoint the prescribers driving competitor share and quantify the addressable opportunity at the physician level. Filter the drug landscape, layer prescriber and plan attributes, and segment by geography or specialty to focus engagement where it will have the highest impact.

Key insights you’ll gain:

Quantify opportunity by prescriber or pharmacy: total Rxs, target drug Rxs, market share, and addressable upside
View opportunity geographically (state, county, city) or by prescriber identity (NPI, name, specialty)
Compare target drug performance against competitors across the entire drug class
Overlay plan-hierarchy fields (Parent Org, Plan Type, Org Market) to align targeting with payer mix
Export targeting lists ready for direct field-force use

Formulary compliance

Benchmark PBM ability to steer volume to preferred agents

Quantify each PBM’s ability to steer volume to preferred drugs and benchmark non-preferred and non-formulary exception rates across the market. Built to inform PBM coverage determination and appeals (CD&A) processes and manufacturer rebate strategy.

Key insights you’ll gain:

Compare preferred, non-preferred, and non-formulary exception rates across PBMs by plan sponsor and drug
Drill into the drug-level breakdown for any PBM to see exactly where steerage holds or breaks
Filter by drug class, brand/generic, or specialty status to focus on the segments that matter
Quantify PBM steerage effectiveness to support contract evaluations and CD&A processes
Inform pharma rebate negotiation strategy with hard evidence on PBM behavior

‘New-to-plan’ adherence

Get 4–5 months of lead time on Star adherence interventions for AEP joiners

Plans ordinarily must wait 5–6 months for current-year claims to reveal adherence gaps among AEP joiners, when much of the year is already locked in and intervention is less effective. By combining Member migration with prior-year adherence data, this module identifies at-risk joiners 4–5 months earlier, giving intervention teams time to act.

Key insights you’ll gain:

Compare adherence of AEP joiners against stayers across the three Stars measures (Diabetes, RASA, Statins)
Break the comparison down by Contract, Prescriber, or Pharmacy to localize intervention opportunities
Slice by PBM, Parent Org, LIS status, or Plan Type
Identify at-risk cohorts 4–5 months before PDC metrics would normally emerge through claims data
Deliver targeted interventions before new-member gaps compound

Concomitant drug therapy

Assess the full drug profile associated with any therapy to inform formulary and market-access strategy

For any drug or drug class, assess the complete utilization and total Part D drug spend across the full drug basket of members taking it, not just the target therapy. Benchmark those results across formularies and plan sponsor coverage strategies to inform formulary design, market access, and value discussions.

Key insights you’ll gain:

Measure total Part D drug spend across the full drug basket of members taking any target drug or class
Benchmark utilization and spend across formularies and plan sponsor coverage strategies
Filter to specialty drugs, brand/generic, or specific GPI levels to isolate the segments that matter
Support class-level coverage decisions by evaluating interchangeable drugs holistically — grounded in each utilizer8217;s complete spend profile, not just the target drug

In active development

Additional modules currently being built to extend the platform — bringing new analytical capabilities for pharmaceutical manufacturers, PBMs, specialty pharmacies, and Part D stakeholders.

Rebate modeling

Model rebate ranges from actual claims, not industry averages

Negotiation-specific rebate modeling built on real Part D experience. Pairs with Formulary shift assumptions for end-to-end rebate strategy.

PLANNED CAPABILITIES

• Rebate ranges tailored to each negotiation
• Layer tier, shift, and volume assumptions
• Every estimate grounded in claims experience

Formulary shift assumptions

Predict how volume moves when formularies change

Sister module to Rebate modeling. Quantifies the volume shift that follows tier moves, exclusions, and UM additions, using two decades of observed Part D behavior.

PLANNED CAPABILITIES

• Shift assumptions from 20 years of Part D data
• Model response to tier moves, exclusions, and UM
• Pairs with Rebate modeling
• For plan sponsors, PBMs, and manufacturers

Formulary benchmarking

See how much of the Medicare market covers a drug

Compare formulary coverage across plans by drug, weighted by member months, tracked month by month.

PLANNED CAPABILITIES

• Member-month-weighted coverage for any drug
• Break out by PBM, plan sponsor, plan type, and more
• See next year’s formulary during AEP
• Monitor mid-year formulary changes in near real time

See MedIntel in action

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