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coverage-exception

io.github.builtforai/coverage-exception
헬스케어 법률 및 컴플라이언스 공개 · 연결 가능 MCP 2026-07-28

이 MCP로 할 수 있는 일

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

기능

도구

2 도구
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.
입력 스키마 
{'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.
입력 스키마 
{'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"'}}}
기록

최근 도구 변경

추가됨
medicare_coverage_restriction_and_exception
2026년 9월 19일 2:40 AM
추가됨
medicare_part_d_out_of_pocket_cap
2026년 9월 19일 2:40 AM
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