PayerIQ
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Tier 2NHCommercial

Sunshine Health MCO

Active pursuit — access summits + value dossier

Composite
61.2
Rank
#114
Members
2.1M
Scoring profile

Six-criterion radar

Breakdown

Weighted score contribution

Claims
25%
83
+20.8
Lives
20%
58
+11.6
Geography
20%
35
+7.0
Restrictions
15%
41
+6.1
Relationship
10%
89
+8.9
Financials
10%
68
+6.8
Composite Score61.2
Composite = Claims×0.25 + Lives×0.20 + Geography×0.20 + Restrictions×0.15 + Relationship×0.10 + Financials×0.10
= 20.8 + 11.6 + 7.0 + 6.1 + 8.9 + 6.8 = 61.2
Intelligence

Qualitative intelligence

Members
2.1M
Drug spend
$0.7B
Formulary
3-tier
PA / RA level
None
Biosimilar policy
Mandatory substitution
Avg reimbursement
51 days
Strategic notes

High claims volume but federal formulary restrictions require CMS waiver pathway

Peer set

Closest peers in Commercial

Arkansas Blue Cross
OK · Tier 2
63.0
+1.8
MDwise HMO
HI · Tier 2
63.4
+2.2
Superior HealthPlan
LA · Tier 2
58.3
-2.9
PreferredOne
RI · Tier 3
58.0
-3.3
Sutter Health Plus
OH · Tier 3
57.2
-4.0
Playbook · Tier 2

Engagement timeline

Week 1
Senior medical director engagement
Week 3
Formulary review submission
Quarterly
Account QBR + utilization review