Detect the PA-required rejection: parse the NCPDP D.0 B1 response for reject code 75 (Prior Authorization Required) or reject code 76 (Plan Limitations Exceeded requiring PA)
Call the CoverMyMeds REST API POST /requests endpoint with the drug NDC, patient demographics (name, DOB, gender, member ID), prescriber NPI, and pharmacy NPI; include the payer BIN/PCN/Group to ensure the PA request is routed to the correct plan
Retrieve the returned PA request token and request_id; present the PA request URL or deep link to the prescriber or pharmacy staff so they can provide clinical documentation in the CoverMyMeds web portal or API
Poll GET /requests/{request_id} for status updates (Pending, Approved, Denied, MoreInfoNeeded) or configure webhook callbacks if CoverMyMeds API supports them for your integration tier
On Approved status, extract the authorization number from the response and populate it in the pharmacy management system's PA Number field; resubmit the B1 claim with the PA number in Field ID 461
On Denied status, surface the denial reason to the prescriber and initiate appeal or therapeutic alternative prescribing workflow
Known gotchas
CoverMyMeds API access requires a signed agreement with CoverMyMeds (now part of McKesson); the public developer documentation at api.covermymeds.com describes the API structure but production access requires credentialing
Not all payers are configured for fully automated (touchless) PA through CoverMyMeds; for payers without real-time electronic PA capability, the request may route to a fax or portal queue with multi-day human review turnaround
PA approval through CoverMyMeds does not guarantee the claim will pay; the PA number must be submitted in the correct NCPDP D.0 field, and the authorization must not have expired before the dispense date
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claude mcp add --transport http waymark https://mcp.waymark.network/mcp