CMS-10558 Schema Screenshots

Appendix A. Machine Readable Schema

OMB Control #: 0938-1284
Expiration Date: XX/XX/20XX

Schema table screenshots pulled from here: https://developer.cms.gov/marketplaceapi/coverage-portal/#/schema
Index Schema
Field

Definition

Required

An array of URLsof JSON fl les that con form t o t he

provider_u rls

provider schema, m inimum of 1 required

An array of URLsof JSON files that con form t o t he

formu lary_urls

f ormulary schema

An array of URLsof JSON fi les that con form t o t he plans

pl an_urls

schema, min imum of 1 requ ired

Yes

Yes

Yes

Drugs Schema
Field

Label

Definition

Drug

RxC UI (Specific drug ident ifie r f rorn

Identifier

RXNORM). Nu llable.

drug_name

Drug Name

Name of Drug

plans

Plans

rx norm_id

Required

Yes

Yes

Array of plans tha t cover t his drug (see
"Plans sub-type" below)

Yes

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 information collection
included in this package reflects the time and effort to produce certain data to CMS in a machine-readable format to increase and
enhance transparency of QHP drug formulary information and of information about providers under health plans. The time required to
complete this information collection is estimated to average less than 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, which includes the time to review instructions, search existing data resources, gather the data needed, to review and complete
the information collection. This information collection, pursuant to 45 C.F.R. § 156.122(d), requires QHP issuers, including Small
Business Health Options Program (SHOP) issuers but excluding stand-alone dental plans (SADP) issuers, to publish an up-to-date,
accurate, and complete list of all covered drugs, known as formularies. All information collected will maintain consumer privacy with
respect to the information disclosed to the extent of the applicable law and HHS policies. 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, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or email Ana Alza at [email protected].

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Appendix A. Machine Readable Schema

Plans Sub-type
Field

Label

Definition

Required

ID Type

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

Yes

Unique
Identifier

The plan ID that was used in the
plans.json as the plan_id value. For
a Marketplace plan, this must be
the 14-digit HIOS plan id.

Yes

drug_tier

Drug Tier

Tier for f ormulary (Example
Values: GENERIC, PREFERREDGENERIC, NON-PREFERREDGENERIC, SPECIALTY, BRAND,
PREFERRED-BRAND, NONPREFERRED-BRAND, ZERO-COSTSHARE-PREVENTIVE, MEDICALSERVICE, etc. Values should be all
uppercase, no whitespace
allowed.)

Yes

prior_authorization

Prior
Authorization
Required

Is prior authorization required? (boolean value: true or false)

No

step_therapy

Step Therapy
Required

Is step therapy required? (boolean value: true or false)

No

quantity_limit

Quantity Limit

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

No

years

Years

Array of years the data covers.

Yes

plan_id_type

plan_id

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Appendix A. Machine Readable Schema

Plans Schema
Field

Label

Definition

Required

plan_id_type

ID Type

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

Yes

plan_id

Unique
Identifier

The 14-character, HIOS-generated
Plan ID number. (Plan IDs must be
unique, even across different
markets.)

Yes

marketing_name

Marketing
Name

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

Yes

summary_url

URL for Plan
Information

The URL that goes directly to the
summary of benefits and coverage
for the specific standard plan or
plan variation.

Yes

marketlng_url

URL for Plan
Information

The URL that goes directly to the
plan brochure for the specific
standard plan or plan variation.

No

fo rmulary_url

URL for
Formulary

The URL that goes directly to the
formulary brochure fo r the specific
standard plan or plan variation.

No

plan_contact

Contact Email
Address for
Plan

An email address for
developers/public to report
mistakes in the network and
formulary data.

Yes

years

Years

Array of years the data covers.

Yes

network

Network

Array of networks

Yes

fo rmulary

Formulary

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

Yes

benefits

Benefits

Array of benefits

No

last_updated_on

Last Updated
On

ISO 8601 fo rmat (e.g. YYYY-MM-DD)

Yes

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Appendix A. Machine Readable Schema

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 taxonomy of network tier names. This value will be used later in the
providers.json file to connect a provider to a specific plan and network tier within that plan.
Field

network_tier

Label

Defi nition

Required

Network
Tier

Tier name for network (Example Values:
PREFERRED, NON-PREFERRED, etc. Values
should be all uppercase, no whitespace
allowed.)

Yes

Formulary Sub-type
This type defines a formulary within a plan. The values 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 formu lary ti er within that plan.

Field

Label

Definition

Required

drug_tier

Drug
Tier

Tier for formulary - (Example Values: GENERIC,
PREFERRED-GENERIC, NON-PREFERREDGENERIC, SPECIALTY, BRAND, PREFERREDBRAND, NON-PREFERRED-BRAND, ZERO-COSTSHARE-PREVENTIVE, MEDICAL-SERVICE, etc.
Values should be all uppercase, no whitespace
allowed.)

Yes

mail_order

Mail
Order

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

Yes

cost_sharing

Cost
Sharing

Array of cost sharing values (see "Cost sharing
sub-type· below)

No

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Appendix A. Machine Readable Schema

Cost Sharing Sub-type

Label

Definition

Required

pharmacy_type

Pharmacy
Type

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

Yes

copay_amount

Copay
amount

Amount of copay, in $ (number)

Yes

copay_opt

Copay option

Qualifier of copay amount (Values:
AFTER-DEDUCTIBLE, BEFOREDEDUCTIBLE, NO-CHARGE, NOCHARGE-AFTER-DEDUCTIBLE).
Nullable.

Yes

coinsurance_rate

Coinsurance
rate

Rate of coinsurance (float, 0.0 to 1.0)

Yes

Coinsurance
option

Qualifier for coinsurance rate (Values:
AFTER-DEDUCTIBLE, NO-CHARGE,
NO-CHARGE-AFTER-DEDUCTIBLE).
Nullable.

Yes

Field

coinsurance_opt

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Appendix A. Machine Readable Schema

Benefits Sub-type
The Benefits sub-typeis an optional section and will be shaped depending on what industry and
consumers find valuable.
For example, many health plans are offering telemedicine as an additional health benefit and
that can be highlighted by adding a telemedicine entry.

Field

Label

Defi nition

Required

telemedicine

Offers
Telemedicine

Does the plan cover telemedicine?
Boolean (values should be either true
or false)

No

Providers Schema

Field

Label

Definition

Required

npi

National
Provider ID

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

Yes

type

Type

Specify if INDIVIDUAL, FACILITY, or
GROUP.

Yes

plans

Plans

Array of plans that cover this pro•tider
(see "Plans sub-type" below)

Yes

last_updated_on

Last
Updated
On

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

Yes

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Appendix A. Machine Readable Schema

If the entry is for an INDIVIDUAL then the following fields
should be present:
Field

name

Label

Definition

Name

A name object, containing name fields
specified below. Ex. {"prefix" : "Dr.
f i r s t ": J ane
"mi ddle":
Gret c hen
"l a s t ": "Smi t h" }
"

Required

"

",

"

Yes

,

"

"

,

prefix

Prefix

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

No

fi rst

First Name

Full first name

Yes

middle

Middle
Name

Full middle name

No

last

Last Name

Full last name

Yes

suffix

Suffix

One of Jr., Sr., II, Ill, Ill, IV

No

addresses

Address

List of addresses for this provider, see
address sub-type below.

Yes

specialty

Specialty
Type

An array of specialty types. Free form text
field.

Yes

accepting

Accepting
Patients

Is the provider accepting new patients? One
of three values: accepting, not accepting,
accepting in some locations

Yes

gender

Gender

Values: Male, Female, Other, Transgenderfema le, Transgender-male, Non-binary, Nondisclose

No

languages

Languages
Spoken

An array of the languages spoken

No

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Appendix A. Machine Readable Schema

If the entry is for a FACILITY then the following fields should be
present:
Field

Label

Definition

Required

facility_name

Facility
Name

-

Yes

facility_type

Facility
Type

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

Yes

addresses

Address

List of addresses for this provider, see
address sub-type below.

Yes

If entry is present for GROUP then the following fields should
be present.
Field

Label

Definition

Required

group_name

Group
Name

-

Yes

addresses

Address

List of addresses for this provider with the
address sub-type below.

Yes

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Appendix A. Machine Readable Schema

Address Sub-type

Field

Label

Definition

Required

address

Street Add ress

-

Yes

address_2

Street Add ress 2

-

No

city

City

-

Yes

state

State
Abbreviation

Two letter state abbreviation (FL IA,

zip

Zip Code

etc.)
Five digit zip code, represented as a
string

Yes

Yes

Plans Sub-type
Field

Label

Definition

Required

plan_id_type

ID Type

Type of Plan ID. For all Marketplaceplans this
should be: HIOS-PLAN-ID

Yes

plan_id

Unique
Identifi er

The plan ID that was used in the plans.json as
the plan_id value. For a Marketplace plan, this
must be the 14-digit HIOS plan id

Yes

netwo rk_tier

Network
Tier

Tier for network (Example Values:
PREFERRED, NON-PREFERRED, etc. Values
should be all uppercase, no whitespace
allowed.) Must match a network tier defined
in the corresponding plan record in a
plans.json fi le.

Yes

years

Years

The years the data is relevant to

Yes

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