Shop by Drug

Quote an individual while evaluating drug coverage

The IFP Medical quoting workflow supports evaluation of prescription drug coverage. This process is commonly referred to as "Shop by Drug", short for shopping for health insurance plans while evaluating drug coverage within the formulary for each quoted plan. The Shop by Drug workflow is a two step process in which the user must first identify the prescription drug(s) to evaluate coverage for.

1. Search for a Drug - use the "Drug Search" endpoint to identify one or more of the end user's drugs.

2. Quote Applicants with Drug Data - quote the end user in the IFP Medical market with the selected drugs, returning available plans and their benefits, premiums, and formulary coverage details. Formulary details include the standardized drug tier, prior authorization, step therapy, and quantity limits, where available.

Search for a Specific Drug

Before drug(s) can be evaluated for coverage in the Shop by Doc flow, they must be identified via the Drug Search API. The "Drug Search" endpoint (API docs) supports look ups by:

• Search Term search_term - the primary means for drug identification. The search term string evaluates partial or full matches against the drug names.

• RxCUI rx_cui - the RXCui identifier from RxNorm, the database maintained by the National Library of Medicine. Each RxCUI identifier provides a consistent, normalized key to represent a clinical drug.

In addition to passing either search_term or rx_cui, we strongly recommend passing require_formulary=true in every call. This limits results to only return drugs present in at least one carrier's formulary, which prevents users from selecting drugs that may exist in the drug dataset but are not covered by any carrier's plans.

Identifying Drugs

A drug in Ideon's data is unique by its med_id, which is Ideon's foreign key for a given drug. A distinct med_id is associated to one or more drug_package_id, which is the standard identifier for drug packages as defined in the FDA's National Drug Code Directory. To evaluate drug coverage via the Shop By Doc flow, the med_id and/or the drug_package_id must be passed when quoting applicants.

Please note that rx_cui is considered the highest level drug identifier. It does not include different packages, forms, or strengths for the drug. It can correspond to multiple distinct drugs, as identified by their med_id's. Given this, the rx_cui is not a valid value to pass in the call to the "Medical Plan Search" endpoint.

Drug Names

The name of the drug is sourced from the RxNorm database. All information in each drug_packages object is sourced from the FDA's National Drug Code (NDC) Directory, including proprietary_name and non_proprietary_name .

The drug various drug name fields can each exceed 2,000 characters. For a user-friendly experience, we recommend displaying the distinct proprietary_name present in the response, and provide an additional option to select an active_ingredient_strength for each of the returned drugs. We also recommend using the full drug name as a fallback, to account for rare instances when the aforementioned fields are missing or empty.

Quote Applicants with Drug Data

Quoting an Individual with Drug Coverage

The med_id and/or drug_package_id identifiers selected in the previous step can be passed in the request body of the "Medical Plan Search" endpoint (API docs) to evaluate drug coverages for each of the quoted plans. Each selected drug should be included in its own object in the drug_packages array, where the drug can be defined by the med_id, drug_package_id (which corresponds to the id in the request schema), or both. We recommend including a maximum of 50 med_id or drug_package_id in each given quote request.

The drug identifiers passed in the drug_packages array are not validated. If the identifiers passed in the drug_packages array are invalid or not found, the quote will succeed and the coverages array in the response will return as an empty array.

Drug Coverage in the Response

If the drug_packages array is included in the request body, then a coverages array will be included in the response schema. An object is included in the coverages array for each unique drug and quoted plan combination for which the drug is covered or not covered in the plan's formulary. For example, if two unique drugs are included in the drug_packages array and each of those drugs is covered by the formulary of three quoted plans, then there will be six objects in the coverages array - one for each combination of the drug and plan.

For each of the objects representing a covered drug-plan combination in the coverages array, the following data points are included:

• Quantity Limit quantity_limit - a boolean indicating whether there is a limitation on the amount or quantity of the drug that will be dispensed.

• Prior Authorization prior_authorization - a boolean indicating whether the plan enrollee is required to obtain approval from the payer before the drug is covered under the benefit.

  • Please note that the process for approval for drugs that require prior authorization is nuanced and can require additional approvals or medical exceptions. We strongly recommend that for any drug for which prior_authorization=true, the coverage status displayed to end users reflects that nuance. We suggest including a note such as "This drug requires prior authorization or, in rare scenarios, a non-formulary exception to be covered by the carrier". This approach ensures accurate representation of drugs that require additional review before coverage is determined and prevents misleading end-user displays.

• Step Therapy step_therapy - a boolean indicating whether the plan enrollee is required to try one or more lower cost or preferred therapies before coverage of the more expensive or alternative drug is permitted.

• Tier tier - this field denotes the cost-sharing or formulary placement level for a drug under a given plan. Please refer to the descriptions for each tier in our API documentation for the "Medical Plan Search" endpoint (API docs).

  • Covered drugs are generally indicated by the following drug tiers when prior_authorization=false: preferred_generic, non_preferred_generic, generic, preferred_brand, non_preferred_brand, specialty, non_preferred_specialty

  • Not covered drugs are indicated by the tier not_covered, meaning the drug is explicitly not covered by the plan's formulary. These drugs should not be displayed as covered under the plan.

  • Not listed drugs are indicated by the tier not_listed, meaning the drug is neither explicitly covered nor excluded. These drugs should not be displayed as covered under the plan.

• Plan Identifier plan_id - identifier for the health plan for which the drug coverage applies to.

• Drug Package Identifier drug_package_id - this identifier refers to the specific packing unit for the drug, as managed within the FDA's NDC directory. Regardless of whether drugs are defined by med_id and/or drug_package_id in the request's drug_packages array, the drug_package_id will be used to identify the drug in the response.