Agadia
Agadia is a privately held healthcare technology company founded in 2007 that provides AI-powered utilization management software, primarily prior authorization automation, to 55+ health plans and PBMs covering 100M+ lives across the United States.
- Company typePrivate
- Founded2007
- HeadquartersParsippany, United States
- Headcount51–100
- GTM typeB2B
- OfferingSoftware
What Agadia does
Agadia is a privately held healthcare management technology company founded in 2007 and headquartered in Parsippany, New Jersey, with a planned relocation to Morris Plains, NJ in early 2026. The company develops AI-powered utilization management software for health plans, pharmacy benefit managers (PBMs), third-party administrators (TPAs), specialty pharmacies, and drug manufacturers, serving 55+ customers covering 100M+ lives across all 50 states and Puerto Rico. Its flagship product, PAHub, is a unified enterprise platform that automates medical and pharmacy prior authorizations using AI, natural language processing, and auto-decisioning capabilities, with HL7 and FHIR interoperability supporting CMS-0057-F compliance and real-time integration with claims systems and EMRs.
The product suite extends beyond PAHub into a broader utilization management portfolio: FormularyHub for formulary benefit design, RxMTM+ for medication therapy management, GrievancesHub for member grievance workflows, RxSentinel+ for opioid utilization management, PAHub Insights for operational analytics, and an ePA Portal for Specialty Drugs serving pharmaceutical manufacturers and hub service companies. Underlying technology includes NLP-driven clinical data extraction from unstructured documents, predictive auto-decisioning, 170-language translation integration via CQ fluency, and HITRUST-certified security. The platform delivers documented outcomes including 133% processing speed increases, 199% first-year IRR for customers, 50% reductions in PA phone volume, 70% operational cost savings, and 386% increases in PA volume for adopters.
Agadia generates revenue through enterprise software licensing and subscription agreements, with custom pricing based on covered lives and solution scope. The company operates a direct enterprise field sales motion with dedicated account teams targeting health plans, PBMs, and TPAs, complemented by self-service demo scheduling, content marketing through its blog and case studies, and channel partnerships with specialty pharmacies and drug manufacturers. Agadia is bootstrapped with no public or private equity backing and reinvests into 8-9 platform enhancement releases annually while maintaining continuous regulatory update cycles tied to CMS rule changes.
Agadia firmographics
Firmographics- Name
- Agadia
- Legal name
- Agadia Systems, Inc.
- Website
- https://agadia.com
- Company type
- Private
- Founded year
- 2007
- Operating status
- Operating
- Headcount range
- 51–100 employees
- Short description
- Agadia is a privately held healthcare technology company founded in 2007 that provides AI-powered utilization management software, primarily prior authorization automation, to 55+ health plans and PBMs covering 100M+ lives across the United States.
- Ownership category
- akta.pro rank
Agadia industry classification
Industry- Product category
- Healthcare Utilization Management Software
- NAICS
- Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Software Publishers (51321)
- SIC
- Services-Prepackaged Software (7372)
- akta.pro primary industry
- PBM Technology Platforms (ePA/eRx/Real-Time Benefit Tools) (HLAEAKAL)
Keywords
Where Agadia is headquartered
LocationHeadquarters
- HQ city
- Parsippany
- HQ country
- United States
- HQ region
- North America
Offices2 records
Markets served
Agadia business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Personnel, Technology or R&D, Marketing or Sales, Operations
Revenue model
- Software Licensing/Subscription: Agadia generates revenue through software licensing and subscription fees for its utilization management platform. The company offers its PAHub platform and related solutions to health plans, PBMs, and TPAs on an enterprise subscription basis, with dedicated account teams providing ongoing support and platform enhancements.
Go-to-market motion2 records
Distribution channels3 records
Marketing channels6 records
Agadia product offering
Product offeringCore offering
Agadia develops and licenses PAHub, an AI-powered enterprise platform that automates medical and pharmacy prior authorizations, formulary management, medication therapy management, grievances and appeals, opioid utilization management, and Star Ratings optimization. The platform is HL7/FHIR ready, HITRUST certified, and supports CMS-0057-F compliance for health plans, PBMs, TPAs, specialty pharmacies, and drug manufacturers.
Product overview
Agadia offers a unified suite of AI-powered utilization management solutions built around its core PAHub platform. The platform spans electronic prior authorization automation (PAHub), formulary management (FormularyHub), medication therapy management (RxMTM+), grievance management (GrievancesHub), opioid utilization management (RxSentinel+), and reporting/analytics (PAHub Insights). Solutions are designed for health plans, PBMs, TPAs, and healthcare organizations, supporting all lines of business (commercial, Medicare, Medicaid) and channels including ePA, phone, fax, web, and EMR integrations.
Differentiator
Problem solved
Functional benefit
Brands
- PAHub: AI-Powered prior authorization automation platform for medical and pharmacy prior authorizations.
- PAHub Insights
- RxMTM+
- FormularyHub
- GrievancesHub
- RxSentinel+
- ClinIntel
Products and services
- PAHub AI-powered enterprise platform that automates medical and pharmacy prior authorizations, supporting HL7 and FHIR interoperability, auto-decisioning, and unified medical and pharmacy utilization management for health plans, PBMs, and TPAs.
- FormularyHub Formulary benefit management solution enabling control over the creation, implementation, and maintenance of custom and standard formularies for health plans and PBMs.
- RxMTM+ Medication therapy management solution enabling efficient management and implementation of MTM programs to meet CMS requirements for health plans and PBMs.
- GrievancesHub Web-based grievance management solution for Health Plans and PBMs to manage and resolve member grievances efficiently while ensuring compliance with CMS requirements.
- RxSentinel+ Opioid and controlled substance utilization management program enabling health plans and PBMs to configure and manage opioid overutilization monitoring and interventions.
- PAHub Insights Reporting and analytics module providing 360-degree prior authorization visibility, 24/7 data access, ad hoc reporting, and drill-down analytics for operational intelligence.
- ePA Portal for Specialty Drugs Electronic prior authorization portal enabling specialty pharmacies, hub service companies, and drug manufacturers to access APIs or an ePA portal to streamline the specialty drug prior authorization process.
Quantifiable outcome
- 133% processing speed increase for prior authorizations
- +4 more outcomes
Companies that use Agadia
Customer profileNamed customers6 records
Segments4 records
Ideal customer profiles3 records
Agadia technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Integration1 record
AI capability5 records
Feature7 records
Agadia partnerships and signals
Strategic signalPartnerships
Three partnerships are on record, tiered core.
- CQ fluencycoreIntegration partnership providing language translation services within PAHub. The integration enables clients to meet language translation needs for templates, explanations, and notification letters during the prior authorization process. PAHub now offers translations in over 170 languages to better aid clients and their members with Limited English Proficient (LEP) populations. CQ fluency is an exclusive translation vendor for CMS and 60+ health plans.
- WellDynecorePartnership agreement for use of Agadia's Prior Authorization Solution, PAHub. WellDyne, a pharmacy benefit management company, leverages PAHub to streamline and control clinical, compliance, and administrative aspects of prior authorization.
- MedOnecoreStrategic partnership with MedOne, a national medication stewardship provider. MedOne uses Agadia's PAHub platform to scale operations while enhancing the level of care provided to members. The partnership enables MedOne to benefit from efficiencies afforded through the PAHub platform for prior authorization processing.
Scale indicators9 records
Recent moves7 records
Expansion highlights5 records
Agadia competitors and assessment
Company assessmentDirect peers
- Surescripts: Operates the dominant electronic prescribing and prior authorization network connecting prescribers, pharmacies, payers, and PBMs. Directly comparable to Agadia in electronic PA workflow orchestration and as a connectivity layer for payer-provider clinical data exchange.
- CoverMyMeds (McKesson): One of the largest electronic prior authorization platforms in the US, serving pharmacies, providers, payers, and PBMs. Competes head-on with PAHub for the same pharmacy and medical PA automation workload.
- EviCore (Evernorth/Cigna): Provides utilization management and medical benefit management services and software to health plans. Directly comparable as a PA/UM solution provider, though operated as part of Cigna's Evernorth vertical.
- HealthEdge Software: Delivers core administrative and care management platforms to health plans, with utilization management as a core workflow. Comparable as a payer technology vendor serving similar buyers with adjacent UM capabilities.
- ZeOmega: Provides the Jiva platform for utilization, care, and population health management to health plans and PBMs. Overlaps with Agadia on PA, MTM, and care management workflows for the same payer customer base.
- Casenet (Zyter/TrialCard): Offers utilization and care management software to health plans, including prior authorization, appeals, and grievances. Direct overlap with Agadia's PA and GrievancesHub workflows within the same payer segment.
- MCG (formerly Milliman Care Guidelines): Provides evidence-based clinical decision support and care guidelines used in utilization management. Comparable as a clinical content and decisioning layer that supports PA workflows for health plans and PBMs.
Broad incumbents
- Change Healthcare (Optum): A much larger healthcare IT incumbent covering claims, eligibility, PA, and analytics. Competes with Agadia on payer-side PA interoperability and analytics, but as part of a far broader portfolio.
- Inovalon: Healthcare data and analytics platform serving payers, providers, and pharma. Comparable on payer-side analytics and decision support (overlapping with PAHub Insights) but operates at much broader scale.
Emerging players
- VirtualHealth: Care and utilization management platform serving health plans and managed care organizations. Comparable on UM and care management workflows but focused more on integrated care management than pharmacy PA specifically.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat4 records
Key risks6 records
Key highlights6 records
Customer concentration
Agadia social profiles
Digital presenceAgadia compliance and trust
Trust signalCompliance2 records
Agadia financial estimates
Financial estimateRevenue estimate
Valuation estimate
Agadia leadership team
Management profileNumber of profiles
Profiles3 records
Agadia funding detail
Funding detailFunding overview
Funding rounds
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
Agadia M&A and investment
M&A and investmentM&A
Investments1 record
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about Agadia
What does Agadia do?
Agadia develops and licenses PAHub, an AI-powered enterprise platform that automates medical and pharmacy prior authorizations, formulary management, medication therapy management, grievances and appeals, opioid utilization management, and Star Ratings optimization. The platform is HL7/FHIR ready, HITRUST certified, and supports CMS-0057-F compliance for health plans, PBMs, TPAs, specialty pharmacies, and drug manufacturers.
Is Agadia a public or private company?
Agadia is a private company. It is classified as founder individual operated bootstrapped and is currently operating.
When was Agadia founded?
Agadia was founded in 2007. It employs 51 to 100 people.
Where is Agadia based?
Agadia is headquartered in Parsippany, United States, in the North America region.
How does Agadia make money?
One revenue line is on record: software Licensing/Subscription.
Who are Agadia's main competitors?
Direct peers on record are Surescripts, CoverMyMeds (McKesson), EviCore (Evernorth/Cigna), HealthEdge Software, ZeOmega, Casenet (Zyter/TrialCard) and MCG (formerly Milliman Care Guidelines). Broad incumbents are Change Healthcare (Optum) and Inovalon. VirtualHealth is listed as an emerging player.
Does Agadia have an API?
Yes. PAHub enables electronic prior authorization workflows that support standardized communication between payers and providers. The platform integrates with HL7 FHIR APIs for secure data exchange across payer, provider, and partner systems. Supports Prior Authorization API for electronic submission and communication of payer determinations.
What industry is Agadia in?
Agadia's product category is Healthcare Utilization Management Software. Its primary akta.pro industry code is HLAEAKAL, PBM Technology Platforms (ePA/eRx/Real-Time Benefit Tools). Its NAICS code is 524292 and its SIC code is 7372.