PokitDok Announces the Release of Pharmacy APIs

Being able to look up pharmacy benefits is difficult. When the time comes to write a prescription, doctors have no way of knowing what medications are covered under a member’s insurance policy - and patients have no idea if a scrip will be covered until they’re through the pharmacy checkout line. Pharmacy benefits have been trapped inside complex, flat formulary PDFs most people don’t even know exist. While strides toward transparency have been made in recent years, we believe in software - and the ability to power a better experience for all parties involved. That’s why we have built a new suite of Pharmacy APIs that enable the ability to look up prescription coverage electronically. The following post outlines each of the APIs we have released along with a look into the code that makes it all possible.

Pharmacy Plans API

The Pharmacy Plans API returns a member's pharmacy plan information including: plan name, premium, deductible, initial coverage limit and copays for each tier (initial coverage phase).

Medicare drug plans have different phases of coverage, including deductible, initial coverage, gap coverage, and catastrophic coverage. Each phase has a different out-of-pocket cost for covered medications. Many Medicare Part D plans use the standard $360 deductible provided in CMS Standard plan design. Some Part D plans do not have a deductible ($0 deductible). For these plans, the member will begin in the Initial Coverage Phase.

Medicare Part D has several phases of coverage: deductible, initial coverage, gap coverage, and catastrophic coverage. The copays included in the Pharmacy Plan Endpoint are coverage during the Initial Coverage Phase.

Medications are grouped into tiers or levels. Plans may have several tiers and the copay for a drug depends on which tier the drug is in. Usually the lower tiers contain less expensive medications and the higher tiers are reserved for more expensive medications.

Each tier level will have either a copay or coinsurance associated with it. The copay will be a dollar amount that the member will be responsible for paying out-of-pocket. Ex. retail_30_day_tier_1_copay The co-insurance will be a percentage of the total cost of the drug that the member will pay out-of-pocket. Ex. retail_30_day_tier_4_coins

Example request to determine pharmacy plan information:

Formulary API

The Pharmacy Formulary API returns specific coverage such as tier level and restrictions including prior authorization, step therapy, and quantity limit as well as details about a medication's out-of-pocket cost and average total cost including insurance reimbursement.

A medication for which coverage is being determined needs to be specified. This can be done using the drug name or NDC. A drug name can include the name of the medication, strength, and form. For example, SIMVASTATIN 10 MG TABLET. Simvastatin is the drug name, the brand name of simvastatin is Zocor, 10 MG is the strength. Medications can come in different strengths. Available strengths of simvastatin are 5mg, 10mg, 20mg, 40mg, and 80mg. The form of this medication is tablet. Some drugs will come in multiple forms. Other examples are capsule, solution, suspension, lotion, cream, etc.

The Pharmacy Formulary Endpoint also accepts national drug code number (NDC). The NDC is a unique 11-digit, 3-segment number used to identify a specific drug product. The segments identify the manufacturer (first 5 numbers), product (middle 4 numbers), and package (last 2 numbers). An alternative way to lookup drug coverage is by using the NDC. One medication can have multiple NDC numbers. For example, simvastatin 10 mg tablets can be supplied to the pharmacy in a 100 count and 1000 count bottle. Both of these will have different NDC numbers even though the same drug is in each of the bottles. If simvastatin comes is bought from two different generic manufacturers, they will have different NDC numbers.

Out-of-pocket costs for medications are based on 30-day supply at retail or 90 day supply at mail order pharmacies. Some medication isn’t taken continuously, ex. antibiotics. For those medications, the member would simply pay one 30-day supply copay. The out-of-pocket amount is the member’s copay if the drug falls into a tier which is covered by a specific copay. For example, a member may have a plan that has a $10 copay for all tier 1 medications. If the medication is tier 1, the member will pay a $10 copay regardless of the actual price of the medication. If the drug is associated with a co-insurance. For example, all tier 4 medications on a member’s plan could have a 25% co-insurance. If the medication is tier 4, the out-of-pocket cost is calculated by taking 25% of the total drug cost.

The total cost is the average cost for the specified days supply at in-network pharmacies. It can vary between plans. For less expensive medications, it usually fluctuates a few dollars. For expensive drugs, the price differences can be in the thousands, depending of course on what plan the member has.

Example request to determine drug coverage using NDC:

In-Network API

The In-Network Pharmacy API returns in-network pharmacies for a plan, or returns the details of a particular pharmacy (such as if it is in-network, if it is a retail pharmacy, etc).

When a doctor writes a prescription, he or she can e-prescribe the medication to a specific pharmacy. This choice doesn’t generally take into account if the pharmacy is in-network for the patient - and most likely, the patient doesn’t know this information either. Most people don’t know they can pick up a prescription at a local, independent pharmacy for the same price as a chain. The In-Network API powers the ability to find an in-network pharmacy that is convenient and cost effective for the patient.

Example searching for in-network pharmacies by plan and zip code:

In sum, the PokitDok team is excited to dive into the pharmacy benefits world. Check out the press release, our API descriptions, or contact us for more information.