Integrate with a PBM's formulary and benefit API to retrieve drug tier, coverage restrictions, and step therapy requirements at the point of prescribing
Access formulary and benefit data through the Surescripts Formulary and Benefit service or a direct PBM API integration; authenticate using OAuth 2.0 client credentials flow with YOUR_CLIENT_ID and YOUR_CLIENT_SECRET
Send a formulary query with patient identifier (member ID or demographics), drug identifier (NDC or RxNorm), and prescriber NPI; receive back FormularyStatus (Covered/NotCovered/NonFormulary), TierNumber, CopayAmount, and CoverageRestrictions array
Parse CoverageRestrictions for codes indicating Prior Authorization Required, Step Therapy Required, Quantity Limit, Age Limit, or Gender Edit; surface these alerts to the prescriber in the order entry workflow
Retrieve step therapy alternative drugs from the response AlternativeMedications list; display alternatives with their tier and estimated patient cost to support shared decision-making
For non-formulary drugs, query formulary exceptions workflow if the PBM supports it; otherwise route to the ePA pathway via NCPDP SCRIPT 2017071
Refresh formulary data at least annually at plan year start (January 1 for most commercial plans) and after any mid-year formulary updates communicated by the PBM
Known gotchas
Formulary data is plan-specific and patient-specific; a drug covered for one patient under a plan may not be covered for another patient under a superficially similar plan with the same insurer due to employer plan design differences
Surescripts formulary data represents the plan-level benefit design and may not include real-time accumulator data (deductible met, out-of-pocket max reached); patient-specific cost share at the point of sale can differ from the formulary-tier cost shown at prescribing
PBMs update formulary files on varying schedules (some weekly, some monthly); query the Surescripts effective date in the response to detect when the formulary data was last refreshed and warn if it is older than expected
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp