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coverage-exception

io.github.builtforai/coverage-exception
Salud Legal y cumplimiento Público y accesible MCP 2026-07-28

Qué hace este MCP

Explains Medicare Part D coverage restrictions, exception and appeal paths, and standard-benefit out-of-pocket cap projections.

Capacidades

Herramientas

2 herramientas
medicare_coverage_restriction_and_exception
For a drug on Medicare Part D, name the coverage problem — covered, prior authorization, step therapy, quantity limit, or not on formulary — and give the exception and appeal path with the CMS-named levels of appeal, who must submit the request, and what to ask the plan and the prescriber. Returns per-plan flag counts across plans held. Plan-specific clinical criteria and appeal deadlines are NOT held and are never inferred; they are returned in an explicit "unavailable" block rather than guessed.
Esquema de entrada 
{'type': 'object', 'required': ['drug'], 'properties': {'drug': {'type': 'string', 'description': 'Brand or generic drug name, e.g. "Humira", "adalimumab"'}, 'state': {'type': 'string', 'description': 'Optional 2-letter US state code, e.g. "TX"'}}}
medicare_part_d_out_of_pocket_cap
Project month-by-month Medicare Part D out-of-pocket spending against the statutory annual cap, identify the month the cap is reached, quantify what the cap itself saves, and compare normal payment timing against the Medicare Prescription Payment Plan — which spreads the SAME total across the year without reducing it. Supports plan years 2026 and 2027 and fails closed to 2026 for any unsupported year rather than extrapolating. This is a standard-benefit simulation, NOT a plan-specific pharmacy quote: plan negotiated prices and plan cost sharing are not held and are never inferred.
Esquema de entrada 
{'type': 'object', 'required': ['monthly'], 'properties': {'drug': {'type': 'string', 'description': 'Optional drug name — checks formulary status and whether spending on it counts toward the cap'}, 'join': {'type': 'string', 'description': 'Optional month (1-12) the payment plan would be joined'}, 'year': {'type': 'string', 'description': 'Optional plan year: 2026 or 2027'}, 'monthly': {'type': 'string', 'description': 'Expected monthly out-of-pocket spend on covered drugs, in USD, e.g. "300"'}, 'deductible': {'type': 'string', 'description': 'Optional plan drug deductible in USD, e.g. "615" or "0"'}}}
Historial

Cambios recientes en herramientas

Añadido
medicare_coverage_restriction_and_exception
19 de September de 2026 a las 02:40
Añadido
medicare_part_d_out_of_pocket_cap
19 de September de 2026 a las 02:40
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