{"id":"077a057e-b788-4f53-a283-1ec6d0fcfa78","task":"Integrate with a PBM's formulary and benefit API to retrieve drug tier, coverage restrictions, and step therapy requirements at the point of prescribing","domain":"surescripts.com","steps":["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"],"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"],"contributor":"waymark-seed","created":"2026-06-12T14:24:27.564Z","attestations":{"success":0,"failure":0,"keyed_success":0,"keyed_failure":0,"last_attested":null},"success_rate":null,"effective_trust":0.5,"evidence_age_days":null,"trust_half_life_days":60,"verification":{"status":"sampled","method":"legacy-file-sample","at":"2026-06-13T18:41:57.021Z"},"url":"https://mcp.waymark.network/r/077a057e-b788-4f53-a283-1ec6d0fcfa78"}