Pharmacy Coverage API V1

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Overview

Effortlessly check a patient’s pharmacy coverage for benefits details and pricing information for specific drugs with hundreds of payers through our RESTful API using JSON components.

We manage NCPDP standards behind the scenes and give you access to out-of-pocket costs, deductible and copay information, additional plan coverage limits, prior authorizations, refill quantity limits, or step therapy requirements in an easy-to-use, human-readable format.

  • Submit a patient's pharmacy insurance, plan number, prescribed medication, and the prescribing provider’s National Provider Identifier (NPI).
  • Receive estimated out-of-pocket costs, deductible and copay information, along with additional plan coverage limits for prior authorizations or refill quantity limits.

API Onboarding

See the Security and Authorization section in this portal to learn more about using our APIs. Most of our APIs are private and require credentials to gain access. After receiving your client_id and client_secret for our sandbox environment, you can test the API from within our interactive documentation, using an application such as Postman, or from your own stack.

To gain access and to speak with us further regarding this API please contact CHCPharmacySales@changehealthcare.com.

Do you have a sandbox that I can test before signing a contract?

Yes, after receiving your client_id and client_secret for our sandbox environment, you can test the API from within our interactive documentation, using an application such as Postman, or from your own stack.

What does a Pharmacy Coverage Request look like?

The following is an example of a Pharmacy Coverage request:

path = '/coverage'
request = 
{
    "pharmacy_npi": "123456789",
    "prescriber": {
        "npi": "123456789",
        "last_name": "ChangeHealthcare"
    },
    "member": {
        "gender": "Male",
        "last_name": "Doe",
        "date_of_birth": "1990-11-26"
    },
    "insurance": {
        "bin_number": "017010",
        "pcn": "05180000",
        "cardholder_id": "123456789",
        "group_id": "1234567"
    },
    "drugs": [
        {
            "ndc": "50090143700",
            "quantity_dispensed": 30
        }
    ]
}

What does a Pharmacy Coverage Response look like?

The following is an example of a Pharmacy Coverage response:

response = 
{
    "globalTransactionId": "33c2c4cd-2918-42cf-a956-df4bee682f19",
    "pharmacyServiceStatus": {
        "ok": true,
        "validNcpdpFormat": true,
        "elapsedTime": 173,
        "exception": false
    },
    "pharmacyServiceOrigin": {},
    "payload": {
        "data": {
            "drugs": [
                {
                    "patient_pay_amount": {
                        "amount": "60.00",
                        "display": "60.00",
                        "currency": "USD"
                    },
                    "additional_information": [
                        {
                            "information": "SINGLE TRANSACTION COB PROCESS USED."
                        }
                    ],
                    "prescription_service_reference_number": "990001373455",
                    "ndc": "62175032246",
                    "quantity_dispensed": "90"
                }
            ]
        },
        "meta": {
            "processing_time": 167,
            "globalTransactionId": "33c2c4cd-2918-42cf-a956-df4bee682f19"
        }
    }
}

What are the Pharmacy Coverage Request parameters and what is required?

The Pharmacy Coverage request parameters are located below: - If field is marked as required (Y) adding this information is required. - If field is not marked as required (N) adding this information is optional.

Field Type Description
pharmacy_npi {string} NPI of Pharmacy
prescriber {dict} Dict of prescriber data
prescriber.last_name {string} Last name of prescriber
prescriber.npi {string} NPI of prescribing physician
member {dict} Dict of member data
member.first_name {string} Member’s First Name
member.last_name {string} Member’s last name
member.birth_date {string} DOB of patient in ISO8601 format (YYYY-MM-DD)
member.gender {enum} Member’s gender: Female, Male, or Unknown
member.address {dict} Dict of member address information
member.address.address_lines {list strings} List of address lines
member.address.city {string} Member city
member.address.state {string} Member state
member.address.zipcode {string} Member zipcode
member.place_of_service {string} Location service took place
insurance {dict} Dict of insurance data
insurance.cardholder_id {string} Cardholder ID (on member’s card)
insurance.bin_number {string} BIN (on member’s card)
insurance.patient_relationship_code {string} Patient relationship code
insurance.pcn {string} PCN (on member’s card).
insurance.group_id {string} Group ID (on member’s card)
drugs {list objects} List of drug objects
drugs.ndc {string} 11 digit NDC of medication
drugs.ingredient_cost_submitted {decimal} Price billed by pharmacy. Useful for calculating coinsurance.
drugs.quantity_dispensed {decimal} Quantity of medication dispensed
drugs.submission_clarification_codes {list} List of submission clarification codes
drugs.prior_authorization_number_submitted {string} Prior authorization number as specified by the payer
drugs.dispense_as_written_product_selection_code {string} Dispense as written code
drugs.scheduled_prescription_id_number {string} Scheduled RX ID number (as required by payer)

What are the Pharmacy Coverage Response parameters?

Pharmacy Coverage responses can be returned with the following information:

Field Type Description
drugs {list objects} List of drug objects
drugs.ndc {string} NDC of drug
drugs.rejections {string} List of exception reasons why price was not available/returned
drugs.patient_pay_amount {object} Information about the patient’s cost for a medication based on the (5Ø5-F5) in the Telecommunication Standard Implementation Guide Version D.Ø NCPDP specification
drugs.patient_pay_amount.amount {decimal} Amount a patient would expect to pay for a drug
drugs.patient_pay_amount.currency {string} Currency that is returned
drugs.patient_pay_amount.display {string} Patient pay amount formatted to be displayed to user
drugs.prescription_service_reference_number {string} Prescription service reference number (Rx billing number) created by Change Healthcare and submitted on transactions for tracking purposes.
drugs.amount_of_copay {object} Information about the patient’s copay (if copay is returned) by a processor
drugs.amount_of_copay.amount {decimal} Copay amount
drugs.amount_of_copay.currency {string} Currency that is returned
drugs.amount_of_copay.display {string} Copay amount formatted to be displayed to the user
drugs.amount_of_coinsurance {object} Information about the patient’s coinsurance (if coinsurance is returned)
drugs.amount_of_coinsurance.amount {decimal} Coinsurance amount
drugs.amount_of_coinsurance.currency {string} Currency that is returned
drugs.amount_of_coinsurance.display {string} Coinsurance amount formatted to be displayed to the user
drugs.additional_information {list objects} List of additional information objects
drugs.additional_information.qualifier {string} Information clarifying the additional_information segment that follows
drugs.additional_information.information {string} Additional Info message text
drugs.history {list objects} Information about the patient’s history regarding the specified medication
drugs.history.previous_date_of_fill {string} Date that the patient last filled a prescription for the specified drug
drugs.history.quantity_of_previous_fill {decimal} Quantity of the previous fill for the specified drug
drugs.history.free_text {string} Free text intended to give more information about the fill requirements if available from the payer.
drugs.history.additional_text {string} Additional information about the fill requirements

How do I get started?

To gain access and to speak with us further regarding this API please contact CHCPharmacySales@changehealthcare.comCPharmacySales@changehealthcare.com)

Change Log

API Name API Version Date Introduced Available Until
Pharmacy Coverage API v1 06/01/2020 TBD

Release Notes:

v1

  • Initial offering of the API.
  • Documentation includes instructions about using this API to:
    1. Submit a patient's pharmacy insurance, plan number, prescribed medication, and the prescribing provider’s National Provider Identifier (NPI).
    2. Receive estimated out-of-pocket costs, deductible and copay information, additional plan coverage limits, prior authorizations, refill quantity limits, or step therapy requirements.