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Real Time Prescription Benefit API

Last updated: November 28, 2017

Published By:
CoverMyMeds, L.L.C.
Columbus, OH 43215
866-452-5017
www.covermymeds.com

Copyright © 2017 by CoverMyMeds, LLC.

RelayHealth RxBenefit Clarity ™ (RBC)

RBC directly queries the PBM for benefit information such as whether PA is required and co-pay amount. By asking the PBM for benefit information directly, the service provides a highly accurate real-time benefit check for the patient.

If sufficient information is supplied (see indicators), then RBC is used for determining the requirements for prior authorization. Otherwise, the /indicators resource uses its machine-learning algorithm to determine whether PA is required for this prescription.

Ux Requirements

There are specific requirements for the user interface when using the RBC information, as detailed below.

Co-pay information will only be returned in the case that the drug being prescribed does not require prior authorization.

Testing the RelayHealth RxBenefit Clarity ™ Integration (RBC)

There are three possible results from a call to the Indicators resource with RBC activated: (These are in addition to those for the generic indicators service)

  1. A drug that does not require prior authorization (PA).
  2. A drug that requires PA and you should allow the physician to initiate PA.
  3. A drug that both requires PA and should be started on behalf of the physician (autostart).

All three scenarios should be tested and for these cases, only the BIN, PCN, and Group ID determine the result. (Any drug name or drug_id will work). You can use the following data:

Scenario BIN PCN Group ID predicted pa_required autostart? additional response(s)
1 111111 norequire rbc-noautostart true false false drug_id = “54569412000”
drug_substitution_performed = true
drug_substitution_help_message = “Price estimate is based on frequently prescribed alternative”
copay_amt = “15.00”
remaining_deductible_amt = “2817.41”
applied_deductible_amt = “27.00”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
pharmacy = “Harris Rx, 2 Miranova PL Columbus, OH 45255”
pharmacy_substitution_performed = true
999999 norequire rbc-noautostart true false false quantity = “30”
quantity_substitution_performed = true
copay_amt = “0.00”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
111111 norequire rxr-noautostart true false false copay_amt = “100.00”
“additional_content”: [{“text”: “Patients can call 1-866-452-5017 or visit the website to determine if they are eligible for financial assistance.”, “method”: “GET”, “href” : “https://www.covermymeds.com/main/epa-solutions/prescribers-pharmacists/”}]
2 111111 require rbc-noautostart true true false sponsored_message = “Product Not Covered”
sponsored_help_message = “This is a helpful message for: Product Not Covered”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
111111 require rxr-noautostart true true false “suggested_drug_alternatives”: [{“name”: “Gabapentin”},{“name”: “DULoxetine HCl”}], “additional_content”: [{“text”: “Assistance with completing and following up on the Prior Authorization is available.”, “method”: “GET”, “href” : “https://www.covermymeds.com/main/help/”}, {“text”: “Common ICD-10 codes used for this medication are: W56.49, W56.22, and V91.07”}]
3 111111 require rbc-autostart true true true sponsored_message = “Prior Authorization Required”
sponsored_help_message = “This is a helpful message for: Prior Authorization Required”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”

The following test cases only function in our master-integration environment (https://master-api.integration.covermymeds.com/indicators?v=1)

Scenario patient member_id patient date_of_birth drug_id rxnorm predicted pa_required? autostart? additional response(s)
1 XA5685683 11/16/2000 54868371800 true false false drug_id = 54569412000
drug_substitution_performed = true
drug_substitution_help_message = “Price estimate is based on frequently prescribed alternative”
copay_amt = “15.00”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
XA5685684 11/17/2000 54868525901 1245449 true false false copay_amt = “0.00”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
2 XA5685684 11/17/2000 00078051005 866303 true true false sponsored_message = “Product Not Covered”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”
3 XA5685685 11/18/2000 00003089321 1364441 true true true sponsored_message = “Prior Authorization Required”
disclaimer_message = “Powered by RelayHealth - The Patient Pay Amount displayed is an estimate at the aforementioned pharmacy above”

/indicators/

The indicators resource returns information of on whether PA is required for a given insurance plan and prescription. When enabled for RBC additional information about the patients benefit is returned.

If CoverMyMeds determines to a high degree that prior authorization is required, the resource returns pa_required: true. If PA is required and enough information is provided to begin PA, the system responds with autostart: true.

Request Required Parameters

Parameter Type Description
Payer
bin bin BIN of the payer
pcn string PCN for the patient’s drug benefit plan (not required if group_id is specified)
group_id string RxGroup of the patient’s drug benefit plan (not required if PCN is supplied)
Patient
member_id string ID number of the patient in the drug benfit plan
first_name string
last_name string
state string US state, 2-digit abbreviation (‘OH’)
zip zip
gender GENDER patient’s sex (’m’, 'f’, or 'u’)
date_of_birth date MM/DD/CCYY formatted
person_code person code 3-digit code assigned to a specific person within a family
relationship_code PATIENT_RELATIONSHIP_CODE “0” (Not Specified) or “1” (Cardholder) or “2” (Spouse) or “3” (Child) or “4” (Other)
medical_record_id_number medical record id number patient medical record identification number (up to 35 characters)
Prescriber
npi npi 10-digit National Prescriber ID
dea_number dea number 2 letters, 6 numbers, and 1 check digit assigned to a provider
last_name string
street_1 string
city string
state string
zip zip
Prescription
drug_id ndc 11-digit code of drug being prescribed
order_id order id prescription order id (up to 35 characters)
Pharmacy
npi npi NCPDP number assigned to the pharmacy
state string US state, 2-digit abbreviation ('OH’)

Request Additional Parameters

Parameter Type Description
rxnorm string 0-15 digit code for drug classes. Used with the RBC Service
{
  "indicator": {
    "request" :  {
      // (if request created)
      // (request is same as response from POST /requests)
    },
    "patient": {
      "first_name":               "string",
      "middle_name":              "string",
      "last_name":                "string",
      "date_of_birth":            "string",
      "gender":                   "GENDER",
      "email":                    "EMAIL",
      "member_id":                "string",
      "pbm_member_id":            "string",
      "phone_number":             "string",
      "person_code":              "string",
      "relationship_code":        "string",
      "medical_record_id_number": "medical record id number",
      "address": {
        "street_1":               "string",
        "street_2":               "string",
        "city":                   "string",
        "state":                  "STATE",
        "zip":                    "zip"
      }
    },
    "payer": {
      "form_search_text":         "string",
      "bin":                      "bin",
      "pcn":                      "string",
      "group_id":                 "string",
      "medical_benefit_name":     "string",
      "drug_benefit_name":        "string"
    },
    "prescriber": {
      "npi":                      "npi",
      "dea_number":               "dea number",
      "first_name":               "string",
      "last_name":                "string",
      "clinic_name":              "string",
      "specialty":                "string",
      "fax_number":               "phone",
      "phone_number":             "phone",
      "address": {
        "street_1":               "string",
        "street_2":               "string",
        "city":                   "string",
        "state":                  "STATE",
        "zip":                    "zip"
      }
    },
    "prescription": {
      "drug_id":                  "ndc or ddid",
      "drug_substitution_performed": "boolean",
      "order_id":                 "order id",
      "name":                     "string",
      "strength":                 "string",
      "frequency":                "FREQUENCY",
      "refills":                  "integer",
      "dispense_as_written":      "boolean",
      "quantity":                 "decimal",
      "days_supply":              "integer",
      "quantity_unit_of_measure": "string",
      "rationale":                "string",
      "pa_required":              "boolean",
      "autostart":                "boolean",
      "predicted":                "boolean",
      "message":                  "string",
      "sponsored_message":        "string",
      "sponsored_help_message":   "string",
      "copay_amt":                "decimal",
      "remaining_deductible_amt": "decimal",
      "applied_deductible_amt":   "decimal",
      "disclaimer_message":       "string",
      "suggested_drug_alternatives": [{name: "string"}],
      "additional_content":       [{name: "string", method: "string", href: "string"}]
    },
    "pharmacy": {
      "npi":                      "ncpdp or npi",
      "name":                     "string",
      "fax_number":               "phone",
      "phone_number":             "phone",
      "address": {
        "street_1":               "string",
        "street_2":               "string",
        "city":                   "string",
        "state":                  "STATE",
        "zip":                    "zip"
      },
      "pharmacy_substitution_performed": "boolean"
    },
    "prediction_id":              "string"
  }
}

Response Additional Parameters

Parameter Type Description
pa_required boolean indicates whether PA is required or not (same as current indicators resource)
autostart boolean indicates whether EHR should start PA automatically (same as current indicators resource)
copay_amt decimal amount of copay for specified drug
remaining_deductible_amt decimal The amount remaining of patient’s deductible
applied_deductible_amt decimal The amount of the patient pay amount applied to the patient’s deductible
predicted boolean true when the indicator was found in the database or RxBC was used to get information about the prescription, false otherwise
message string text about the prescription supplied from RelayHealth
sponsored_message string information about the prescription from the drug sponsor
sponsored_help_message string A help message explaining sponsored_message
drug_substitution_performed boolean indicates whether or not the information supplied is for the prescription as written, or for a generic substitution
quantity_substitution_performed boolean indicates whether or not a different quantity was used to determine the copay_amt or the pa_required value
pharmacy_substitution_performed boolean indicates whether or not default pharmacy logic was used to determine the copay_amt or the pa_required value
suggested_drug_alternatives array[string] indicates generic alternatives for the drug requested
additional_content array[string,string,string] provides information to aid the prescriber with additional clinical or administrative details
prediction_id string unique prediction identifier