Open to anyone.
Methodology & Data Transparency
This is how Callara compiles OTC benefit revenue figures, plus the gaps we know about. Every dollar figure we publish traces to a carrier-published 2026 Summary of Benefits or Evidence of Coverage document, with the quoted amount and source URL recorded.
What's on this page vs under NDA
We publish our methodology at the principles level publicly: what we claim, what we don't, how we handle uncertainty, and our audit coverage. The full implementation packet (matching architecture, reference tables, per-state carrier-network maps, Verification Protocol, reproducibility walkthrough, and open-items tracker) is shared with prospective clients, auditors, and consultants under NDA. Scroll to the bottom to request it.
Our approach
For every Medicare Advantage plan in your state, we cross-reference three progressively more accurate sources:
- 1.CMS Plan Benefit Package (PBP) filings as the conservative floor for plans we haven't individually reviewed.
- 2.Summary of Benefits (SoB) PDFs published by the carrier, for exact per-PBP dollar amounts.
- 3.Evidence of Coverage (EOC) documents, the legally binding contract, for disambiguation and operational rules.
Network routing, capturability, and state-specific variation are threaded through every patient match. The result is a conservative, defensible revenue opportunity figure per pharmacy.
Coverage at a glance
| State | Status | EOC-confirmed plans |
|---|---|---|
| North Carolina | Founding market, deep coverage | 92 |
| South Carolina | Founding market, full coverage | 40 |
| Tennessee | Founding market, near-full | 73 |
| California | Expansion market, pending | 0 |
| Kentucky | Expansion market, pending | 0 |
| Mississippi | Expansion market, pending | 0 |
| Total (founding markets) | 205 / 217 (94.5%) | |
Expansion states have state pricing logic and carrier-landscape briefs in place. Per-PBP EOC entries populate only after a prospect pharmacy onboards, so population is volume-prioritized against real patient cohorts rather than speculative.
The honesty model
We publish five categories of claim. Each has a different evidentiary standard and confidence tier exposed in our dashboard.
| Category | Confidence |
|---|---|
EOC / Summary of Benefits confirmed Carrier-hosted PDF read directly, verbatim quote recorded. | High |
CMS baseline CMS filing data, no direct EOC read yet. Conservative floor. | Baseline |
Commercial-logic inference Industry structure forces a conclusion; direct confirmation pending. | Inferred |
Cross-state extrapolation Confirmed in one state, applied to the same plan in another absent contrary evidence. | Baseline |
Classification inconsistency flagged Internal contradiction in our own data. Surfaced as pending verification until resolved. | Pending |
97% of entries across 200+ MA plans in our founding states meet the EOC-confirmed bar. The rest are transparently labeled as baseline or pending.
What we claim
- Network routing is highly accurate (over 98%). We know which plans route through which OTC processor (NationsBenefits, ProHealthConnect, InComm OTC Network), software apps on generic Android POS hardware. Stable regulatory and carrier data.
- Pharmacy-capturable vs not is accurate. We distinguish between benefits processable in-store and benefits locked to mail-order, CVS-only, or member-portal-only channels.
- Every EOC-confirmed amount is traceable to a specific carrier-published PDF, with the exact quoted text recorded in our system.
- State awareness is comprehensive across our founding markets (NC, SC, TN). A plan that routes differently by state gets different reference data per state.
- Combined flex cards are split conservatively. Where Medicare Advantage plans bundle OTC with groceries, utilities, and other benefits, we track the pharmacy-capturable OTC-only portion separately from the full combined-flex allowance.
What we do NOT claim
- We do not claim 100% precision on dollar amounts. Where we only have CMS filing data, the figure is a conservative minimum. Actual amounts may be higher. We never inflate.
- We do not claim real-time balance visibility. We know what a plan entitles a member to receive. We don't know how much they've already spent this quarter. Balance is gated behind each OTC network's member portal.
- We do not claim capture rate equals opportunity. Capture depends on outreach, signage, and staff comfort. We measure those separately. The opportunity figure is a ceiling on what's reachable with effective outreach.
- We do not claim per-state equivalence. Expansion markets (CA, KY, MS) have groundwork in place but per-PBP precision populates only after prospect patient data arrives.
- We do not claim to capture Kaiser-locked plans. In California, Kaiser Permanente members (30 to 40% of the MA population) fill at Kaiser pharmacies only. We exclude them from capturable revenue and surface their count separately.
The reproducibility promise
Every dashboard revenue figure traces back to source data in a documented chain. Pick any patient record. Follow it to our plan reference tables. Read the notes field for the carrier website URL plus verbatim SoB quote. Open the PDF and verify the quote matches. Every amount on our dashboard is reproducible this way. Under NDA, we walk auditors through the full step-by-step trace for any plan they choose.
Open audit items
We track open audit items in a live Provider Verification Log. A handful of questions are pending direct carrier confirmation at any given time. None of them block our public revenue claims; each is handled by flagging or by conservative-default classification. At a thematic level, open items tend to fall into categories like:
- SNP variants (D-SNP / C-SNP) where retail acceptance can differ from the standard plan and needs per-network confirmation.
- Plans transitioning between mail-order and retail processing for the new plan year.
- Carrier programs that may require a specific enrollment addendum to capture at retail.
- Cross-state routing differences for national carriers, where the same plan can process differently by state.
The specific carriers, processors, verification findings, call scripts, and resolution dates live in the internal Provider Verification Log. Full details available under NDA.
Full methodology review under NDA
The full implementation packet includes our matching architecture, state-by-state carrier-network maps, EOC Verification Protocol, Reproducibility Walkthrough, Provider Verification Log, and operational reference for pharmacy staff. We share it with prospective clients, industry consultants, and auditors under a standard NDA.
Request access: jack@callara.ai