Form CMS-10558 QHP Provider Formulary

OMB Control # 0938-1284
Expiration Date: XX/XX/2023
Appendix A

CMSgov / QHP-provider- formulary-APls

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latest commit fa3cf82 on Aug 30, 2016

paulsmith Fix coinsurance option enum

data

Add GROUP provider type

4 years ago

developer

Sample Issuer Site with index

5 years ago

initial checkin

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§) LI CENSE
§) README.md

Fix coinsurance option enum

4 years ago

cms-data -indexjson

Sample Issuer Site with index

5 years ago

index.html

Add index document read me and schema

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index_document.md

SADP don't have formulary urls

4 years ago

index_document_schema.json

Dental insurers might not have formularies

4 years ago

README.md

Developer Documentation
Learn how to describe what providers and drugs are covered by a particu lar health plan

JSON
All information must be described in the JSON file format JSON is a lightweight and simple way to represent machinereadable data. It is qu ick ly becoming the de facto standard for shuttling data across the internet, fue led primarily by the rise
of mobile and APls. Modern programming languages can interpret and produce JSON out of the box.
Learn about JSON >

Public Discoverability
Organizations must post their index.json , plans.json, providers.json , and drugs.json files on a webs ite, accessible to
the pub lic.

The JSON URLs listed above must be provided over HTTPS to ensure the integrity of the data.

Data types
Al l va lues in the JSON are strings, unless otherwise noted in the Definition field.
Dates should be strings, in ISO 8601 format (e.g. YYYY-MM-DD).

PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1284. The time required to complete this
information collection is estimated to average 136 hours per response for new QHP issuers and 64 hours per response for new SADP issuers in
the first year, and 36 hours for returning QHP issuers and 18 hours for returning SADP issuers in the first year. These estimates include the time
to review instructions, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical
records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Joshua Van
Drei at [email protected].

Health Plans - plans.json
Description
plans. j son co ntains a list of health plans and the ir corresponding network of providers and formularies.

Schema
Field

Definition

Label

plan_id_type

Type of Plan ID. For all Marketplace plans this should be: HIOS-

ID Type

plan_id

PLAN - ID

Unique

The 14-character, HIOS-generated Plan ID number. (Plan IDs must

Identifier

be unique, even across different markets.)

Marketing

marketing_name

Name

summary_url

marketing_url

formulary_url

URL for Plan

The URL that goes directly to the summary of benefits and

Information

coverage for the specific standard plan or plan variation.

URL for Plan

The URL that goes directly to the plan brochure for the specific

Information

standard plan or plan variation.

URL for

The URL that goes directly to the formulary brochure for the

Formulary

specific standard plan or plan variation.

Contact Email
Address for

plan_contact

Plan
network

Net work

formulary

Formulary

benefits

Benefits
Last Updated

last_updated_on

On

years

The name of the plan as it is displayed on HealthCare.gov

An email address for developers/public to report mistakes in t he
netwo rk and formulary data.

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Array of networks
A list of formulari es or a single formulary associated with this plan.
Both a list of formularies or a single formulary are valid.

Yes

Array of benefits

No

ISO 8601 format (e.g . YYYY- MM-DD)

Yes

An array of years for which the plan is offered on the marketplace

Years

Required

(eg., 2016, 2017).

Yes

Network sub-type
This type defines a network within a plan. The values should be something that is meaningful to an issuer, there is no
t axonomy of network tier names. This value will be used later in the providers.json file to connect a provider to a specific
p lan and network tier within that plan.

Field

network_tier

Label

Definition

Network

Tier name for network (Example Va lues: PREFERRED ' NON - PREFERRED ' etc.

Tier

Values should be all uppercase. )

Required
Yes

Formulary sub-type
This type defines a formulary withi n a plan. The va lues should be something that is meaningful to an issuer, there is no
taxonomy of formulary tier names. This value will be used later in the drugs. json file to connect a drug to a specific plan
and formulary tier within that plan.

Field

Label

Definition

Required

Tier for formu lary - (Example Values: GENERIC' PREFERRED-GENERIC ' NON -

drug_tier

Drug

PREFERRED-GENERIC, SPECIALTY, BRAND, PREFERRED-BRAND , NON-PREFERRED-

Tier

BRAND' ZERO-COST-SHARE-PREVENTIVE ' MEDICAL-SERVICE ' etc. Values should be all

Yes

uppercase.)
Mail

mail_order

Order
Cost

cost_sharing

Sharing

Does the formulary cover mail o rder? - (Values: true or false )

Yes

Array of cost sharing va lues (see "Cost sharing sub-type" below)

No

Cost sharing sub-type
Field

Definition

Label
Pharmacy

pharmacy_type

Type
Copay

copay_amount

amount

copay_opt

coinsurance_rate

coinsurance_opt

Pharmacy type (Example Values: 1-MONTH-IN-RETAIL , 1-MONTH-OUTRETAIL , 1 - MONTH- IN- MAIL, 1 - MONTH - OUT- MAIL , 3 -MONTH- IN - RETAIL , 3-

Amount of copay, in $ (number)
Qualifier of copay amount (Va lues: AFTER - DEDUCTIBLE' BEFORE -

option

DEDUCTIBLE , NO- CHARGE , NO- CHARGE-AFTE R-DEDUCTIBLE

Coinsurance

Yes

MONTH-OUT - RETAIL , 3- MONTH-IN-MAIL, 3- MONTH- OUT -MAIL )

Copay

rate

Required

Rate of coinsurance (float, 0.0 t o 1.0)

Coinsurance

Qualifier for coinsurance rate (Values: AFTE R-DEDUCTIBLE , BEFORE-

option

DEDUCTIBLE , NO- CHARGE , NO- CHARGE-AFTER - DEDUCTIBLE)

Yes

Yes

Yes

Yes

Benefits sub-type

The Benefits sub-type is an opt ional section and will be shaped depending on what industry and consumers find valuable.
For example, many health plans are offering telemed icine as an additional health benefit and that can be highlighted by

adding a telemedicine entry.
Field

Label

telemedicine

Definition

Offers

Does the plan cover telemedicine? Boolean (values should be eith er

Telemedicine

true or f alse )

Example plans.json

[ { "plan_id_type":
"HIOS - PLAN - ID",
"plan_ i d" : "12345XX9876543 ",
"years": [2016 , 2017 ],

"market ing_name ": "Sample Gold Health Pl an",
"s urnmary_ url ": "ht tp:/ / url/t o/summary / be nefit s/ coverage ",
"marketing_url" : "http :/ / ur I / to/ health/ plan/i nformation" ,
"formul ary_url ": "http : //url/ t o/f ormul ary/ information" ,
"plan_contact ": "email@address .com" ,
"network ": [
{
"network_tier": "PREFERRED"

},
{

Required

No

"network_tier " : "NON-PREFERRED"

} ],
"formulary": [
{
"drug_tier": "BASIC",
"mail_order": true,

"cost_sharing": [
{

"pharmacy_type": "1-MONTH-IN-RETAIL",
"copay_amount": 20 . 0,
"copay_opt" : "AFTER-DEDUCTIBLE",
"coinsurance_rate" : 0.10,
"coinsurance_opt" : "BEFORE-DEDUCTIBLE"
},
{
"pharmacy_type": "1-MONTH-IN-MAIL",
"copay_amount": 0.0 ,
"copay_opt": "NO-CHARGE",
"coinsurance_rate" : 0. 20,
"coinsurance_opt": null

}]
},
{
"drug_tier": "PREFERRED",
"mail_ order": true,
"cost_sharing": [

{
"pha rmacy_type" : "1-MONTH-IN-RETAIL",
" copay_amount ": 20.0,
"copay_opt": "AFTER-DEDUCTIBLE",
"coinsurance_rate": 0.10,
"coinsurance_opt": "BEFORE-DEDUCTIBLE"
},
{
"pharmacy_type": " 1 -MONTH-IN-MAIL",
"copay_amount": 0.0,

"copay_opt" :

"NO-CHARGE",

" coinsurance_rate" : 0. 20,
" coinsurance_opt": null

}]}

],
"last_updated_on": "2015-03-17" } ]

Providers - providers.json
Description
providers.json contains a list of providers and the plans that cover their services.
If a provider has more than one NPI number, please creat e separate entries for each NPI number. If there is no NPI number,
set the va lue to null ( {"'npi": null})

Schema
Field

Label
National

npi

Provider
ID

Definition
The 10-digit National Provider Identifier (NPI) is a unique identification
number for covered health care providers

Required

Yes

Label

Field

Definition
One of:

Type

type

INDIVIDUAL , FACI LITY ,

maps to NPI type 1, while

or

FACI LITY

GROUP .

and

Required
For reference,

GROUP

I NDIVIDUAL

correspond with NPI

Yes

type 2.

plans

Plans

last_updated_on

Updated

Array of plans that cover this provider (see "Plans sub-type" below)

Last

Date of when the record for th is provider has been last updated or
refreshed - ISO 8601 format (e.g. YYYY-MM-DD)

On
If the entry has
Field

I NDIVIDUAL

Yes

Yes

type, th en t he following fields should be present:

Label

Definition

Required
Yes

name

Name -

prefix

Prefix

One of Mr ., Mrs. , Miss, Ms. , Dr.

No

first

First Name

Full first name

Yes

Full middle name

No

middle

Middle
Name

last

Last Name

Full last name

Yes

suffix

Suffix

One of

No

addresses

Address

List of addresses for this provider

address

address_2
city

Jr. , Sr. , II , III , III , IV

Yes

St reet

Yes

Address Street

No

Address 2 City -

state
zip

Yes

State
Abbreviation
Zip Code

phone

specialty

accepting
gender
languages

If the entry has
Field

Phone
Number
Specialty
Type

Two letter state abbreviation (FL, IA, etc.)

Yes

Five digit zip code, represented as a string

Yes

Phone number for this address, represented as a string of numbers

Yes

An array of specialty types. Free form text field .

Yes

Accepting

Is the provider accepting new patient s? One of three values: accepting , not

Patients

accepting , accepting in some locations

Gender

Values: Male , Female , Other

No

An array of the languages spoken

No

Languages
Spoken
FACILITY

type, then the following fields shou ld be present:
Label

facility_name

Facility Name -

facility_type

Facilit y Type

Definition

Required
Yes

An array of facility types. Free-form text field.

Yes

Yes

Field

Label

Definition

addresses

Address

address

St reet Address -

Yes

address_2

Street Add ress 2 -

No

city

City -

Yes

state

Stat e Abbreviation

Two letter state abbreviation (FL, IA, etc.)

Yes

zip

Zip Code

Five digit zip code, represented as a string

Yes

phone

Phone Numb er

Phone number for this address, st ring

Yes

If the entry has

GROUP

List of ad dresses for this facility

Required
Yes

type, t hen the following fields should be present:

Field

Label

Definition

Required

group_name

Group Practice Name -

Yes

addresses

Add ress

address

Street Address -

Yes

address_2

Street Address 2 -

No

city

City -

Yes

state

State Abbreviation

Two letter st ate abbreviation (FL, IA, etc.)

Yes

z ip

Zip Code

Five d igit zip code, represented as a string

Yes

phone

Phone Number

Phone number for t his address, string

Yes

List of addresses for t his facility

Yes

Plans sub-t ype
Field

Label

plan_id_type
plan_id

network_tier

years

Definition

Required

ID Type

Type of Plan ID. For all Marketplace plans this should be:

Unique

The plan ID that was used in the plansjson as t he pl an_id va lue. For a

Identifier

Market place plan, this must be the 14-digit HIOS plan id.

Network
Tier

Years

Tier for network (Example Va lues:

Yes
Yes

et c. Values
Yes

corresponding plan record in a plans.json fi le.
An array of yea rs for which the plan is offered on the marketplace (eg., 2016,
2017).

[ { "npi":
"1234567893",
"type": "INDIVIDUAL",
"name": {

"fir st": "Sarah",
"middl e" : "Maya",

"last": "Ngyuen" ,
"suffix" : "Jr."
},

PREFERRED, NON-PREFERRED,

should be all uppercase.) Must mat ch a network t ier defined in the

Example providers.json

"addresses": [ {

HIOS - PLAN-ID

Yes

"address ": "123 Main St",
"address_2" : "Suite 120",
"city" : "Little Rock",
"state" : "AR",
"zip": "72201",
"phone": "202S5S1212"
},
{

"address " : "675 South St",
"ci ty": "little Rock",
"state" : "AR",
"zip" : "72201",
"phone": "202S5S1212"
}
],
"spec ialty" : [ "Ophthalmology", " Endocrinology"],
"accepting": "accepting",
"plan s " : [
{
" plan_id_type ": "HIOS-PLAN- ID",
" plan_id": "1234SXX9876S43",
" network_tier": "PREFERRED" ,
"years " : [201 6 ]
},
{
" plan_ i d_type " : "HIOS-PLAN-IO",
" plan_ i d" : "1234SXX9876543",
" network_tier " : "NON-PREFERRED",
"years": [2016, 2017]

) ],
"languages": [ "English", "Spanish", "Mandar in " ],
"gender" : "Female" ,
"last_updated_on" : " 2015-03- 17"
},
{

"npi": "1 234567894",
"type" : " FACILITY",
"facility_name": "Main Street Hospital",
"facility_type " : ["Hospit a l" , "Dialysi s "] ,
"addresses": [
{
"address": "123 Main St",
"address_2 " : "Suite 120",
"city": "Little Rock" ,
" state": "AR" ,
"zi p": "72201",
"phone": "2025551212"
}

],
"plans": [ {
" pl an_ i d_type" : "HIOS- PLAN-ID",
" pl an_id": "12345XX9876543",
" networ k_tier ": "PREFERRED" ,
"years " : [201 7]
},
{

" plan_ id_ type": "HIOS- PLAN-ID" ,
" plan_id": " 1234SXX9876543",
"network_ tier " : "NON- PR EFERR ED",
"years": [2016]

} ],
"last_updated_on": "2016- 04-13"
},
{

"npi " : "1 234567895",
"type": "GROUP ",
"group_name" : "North Main Physic i ans Group",

"addresses": [

{
"address": "234 N Main St",
"address_2": "",
"city" : "Fayetteville",
" state": "AR",
"zip": "72701",

"phone": "2025551313"
}

],
"plans ":

[{
" plan_id_type ": "HIOS-PLAN-10",
"plan_ id": " 1234SXX9876543",
"network_tier": "PREFERRED",
"years": [2017]

},
{
"plan_id_type": "HIOS-PLAN-10",

"plan_id": "12345XX9876543",
"network_tier": "NON-PREFERRED",

"years": [2016]

} ],
"last_updated_on": "2016-05-31" } ]

Drugs - drugs.json
Description
drugs. json contains a list of drugs and the plans that cover them.

Schema
Field

Label

Definition

Required

rxnorm_id

Drug Identifier

RxCUI (Specific drug identifier from RXNORM)

Yes

drug_name

Drug Name

Name of Drug

Yes

plans

Plans

Array of plans that cover this drug (see "Plans sub-type" below)

Yes

Plans sub-type
Field
plan_id_type

plan_id

Definition

Label
ID Type

Type of Plan ID. For all Marketplace plans this should be:

HIOS-

PLAN-ID

Unique

The plan ID t hat was used in the plans.json as the plan_i d value.

Identifier

For a Marketplace plan, this must be the 14-digit HIOS plan id.
Tier for formulary (Example Va lues:

drug_tier

Required

Drug Tier

Yes

Yes

GENERIC , PREFERRED -GENERIC ,

NON- PREFERRED - GENERIC , SPECIAL TY , BRAND , PREFERRED- BRAND ,

Yes

NON-PREFERRED - BRAND , ZERO-COST-SHARE- PREVENTIVE, MEDICAL SERVI CE ,

etc. Values should be all uppercase.)

Prior

prior_authorization

Authorization
Required

Is prior authorization required? - (boolean va lue: true o r f alse )

No

Field

Label
Step Therapy

step_therapy

Required

quantity_limit

years

Definition
Is step t herapy requ ired? - (boolean value: true o r false)

Quantity

Is there a quantity limit for this drug? - (boolean value: true or

Limit

false )

Years

An array of years for which the plan is offered on the marketplace
(eg., 2016, 2017).

Example drugs.json

[ { "rxnorm_id": "209459",

"drug_name": "Acetaminophen 500 MG Oral Tablet [Tylenol]",

"plans": [
{

"plan_id_type": "HIOS-PLAN-10",
"plan_id": "1234SXX9876S43",
"drug_tier": "GENERI C",

"prior_authorization": false,
"st ep_therapy ": fa l se,
"quantity_limit": false,

"years " : [2016 , 2017]
},
{
"plan_ id_ type": "HIOS-PLAN-10",
"plan_id": "12345XX987654 6" ,
"drug_tier": "GENERI C",

"prior_authorization": false,
"step_therapy": false,
"quantit y_limit": false,
"years " : [2016, 2017]

} ] },
{
"rxnorm_id": "248656",

"drug_name": "Azithromycin 500 MG Oral Tablet [Zithromax] ",

"plans": [
{
"plan_id_type ": "HIOS- PLAN-10",

"plan_id": "12345XX9876543",
"drug_tier": "GENERI C",
"prior_authorization": false,
"s t ep_therapy ": false,
"quantity_limit": true,
"years" : [2016]
},
{

"plan_ id_type": "HIOS-PLAN-ID",
"plan_id": "1234SXX9876546",
"drug_tier": "GENERIC",
"prior_authorization": false,
"step_ therapy": false,
"quantity_ limit": false,
"years " : [2017] } ] } ]

Required

No
No
Yes