{"uid":"cap_0nDQnMXUQm_YHYHvSyXrg","slug":"cms-medicare-part-d-formulary-coverage-lookup-faf78e60","name":"CMS Medicare Part D Formulary Coverage Lookup","description":"Medicare Part D drug coverage from CMS monthly formulary files, current and next plan year: for a drug (name or RxCUI), in one plan, across a state's plans or over every formulary: coverage per strength, cost-share tier, prior authorization, step therapy, quantity limit, IRA negotiated-price flag, 30-day retail/mail cost, plan premium and deductible. Includes the CMS release date.","url":"https://api.healthtravel-api.workers.dev/api/health/formulary-coverage-lookup?utm_source=zero.xyz","method":"GET","headers":{},"bodySchema":{"type":"object","$schema":"https://json-schema.org/draft/2020-12/schema","required":["input"],"properties":{"input":{"type":"object","required":["type","method"],"properties":{"type":{"type":"string","const":"http"},"method":{"enum":["GET"],"type":"string"},"queryParams":{"type":"object","required":["drug"],"properties":{"drug":{"type":"string","description":"Drug name (generic or brand, e.g. atorvastatin, Eliquis) or an RxCUI"},"plan":{"type":"string","description":"Optional plan id CONTRACT-PLAN[-SEGMENT], e.g. H0028-007 or S4802-075"},"year":{"type":"string","description":"Plan (contract) year, e.g. 2026 or 2027. Default: the current year if loaded, else the newest"},"limit":{"type":"integer","description":"Max plans in a state listing, 1-100 (default 20)"},"state":{"type":"string","description":"Optional 2-letter state: list the plans sold there with this drug's coverage"}}}},"additionalProperties":false}}},"responseSchema":null,"example":null,"exampleRequest":null,"tags":["x402"],"displayCostAmount":"0.003","displayCostAsset":"USDC","priceDynamic":false,"priceHint":null,"priceStatus":"priced","priceSource":"probe","requiresHandshake":false,"reviewCount":0,"rating":{"score":"0.00","successRate":"0.00","reviews":0,"stars":null,"state":"unrated"},"availabilityStatus":"unknown","priceObserved":null,"sessionDeposit":null,"pricing":{"kind":"static","summary":"$0.003/call","primary":{"kind":"static","protocol":"x402","network":"base","amountUsd":"0.003","per":"call","confidence":"exact"},"accepted":[{"kind":"static","protocol":"x402","network":"base","amountUsd":"0.003","per":"call","confidence":"exact"}]},"paymentMethods":[{"uid":"pm_ZFRlZbwSP1pbI8-axcWo0","protocol":"x402","methodType":"crypto","chain":"base","mode":"charge","costAmount":"0.003","costPer":"request","priority":0,"asset":"0x833589fCD6eDb6E08f4c7C32D4f71b54bdA02913","unit":"request","depositMicros":null,"planRef":null}],"brandName":null,"brandSlug":null,"brandBaseUrl":null,"brandDocsUrl":null,"whatItDoes":"Looks up Medicare Part D drug coverage details—tier, cost-sharing, PA, step therapy, quantity limits, and 30-day costs—from CMS monthly formulary files for a given drug, plan, or state.","exampleAgentPrompt":"What does Medicare Part D plan H0028-007 cover for Eliquis — is there prior authorization, step therapy, or a quantity limit, and what's the 30-day retail cost for the 5 mg strength?","exampleUseCases":[{"title":"Checking drug coverage before enrolling","prompt":"I'm comparing Medicare Part D plans in Florida — can you show me which plans cover Ozempic, what tier it's on, and whether any have prior authorization or step therapy requirements?"},{"title":"Estimating out-of-pocket drug costs","prompt":"How much would a 30-day supply of atorvastatin 40 mg cost me under Medicare plan S4802-075, including the retail and mail-order prices and the plan's deductible?"},{"title":"Verifying IRA negotiated pricing","prompt":"Is metformin flagged as an IRA negotiated-price drug under Medicare Part D for 2026, and what does coverage look like across plans in California?"}],"resultDescription":"Returns formulary coverage details per drug strength including cost-share tier, prior authorization status, step therapy requirements, quantity limits, IRA negotiated-price flag, estimated 30-day retail and mail-order costs, plan premium and deductible, and the CMS data release date. When querying by state, returns a list of up to 100 plans covering that drug.","failureModes":["Drug not found in CMS formulary — returns empty or not-covered result","Invalid plan ID format returns an error or no results","Requested plan year data not yet loaded — falls back to newest available year","State code not recognized — returns error or empty plan list","Drug name ambiguous across multiple RxCUIs — may return partial matches","CMS formulary file not yet updated for current month — data may be slightly stale"],"whenToPreferThis":"Use this endpoint when you need authoritative, CMS-sourced Medicare Part D formulary data — including tier placement, PA/step therapy/quantity limit flags, IRA negotiated prices, and actual 30-day cost estimates — for a specific drug, plan, or across an entire state. Prefer it over general pharmacy benefit lookups when the user explicitly has a Medicare Part D plan or is comparing Medicare coverage options. It covers both current and next plan year, making it ideal for open enrollment decision support.","instructions":null,"reviewSummary":null,"reviewSummaryHighlights":null,"reviewSummaryConcerns":null,"reviewSummaryGeneratedAt":null,"activationCount":0,"lastUsedAt":null,"lastSuccessfullyRanAt":null,"lastHealthCheckAt":"2026-10-29T00:33:53.841Z","isFirstParty":false,"canonicalSlug":"cms-medicare-part-d-formulary-coverage-lookup-faf78e60"}