# Benefily

> Cross-payer prior authorization requirements, with the source cited

Benefily answers one question precisely: **does a given Medicare Part D payer require prior
authorization for a given drug?** Answers are deterministic projections of payers' own formularies
as filed with the Centers for Medicare & Medicaid Services. No model sits in the path — identical
input always returns identical output — and every answer cites the source document and its
effective date.

## What this covers, and what it does not

COVERS: Medicare Part D outpatient prescription drug benefits (Medicare Advantage Prescription Drug
plans and standalone Part D plans), for 1,124,586 formulary rows across 5,496 Medicare Part D plans from 317 payer brands, covering 6,128 drug products, of which 319,047 rows carry a prior-authorization requirement. Formulary effective date: 2026-06-30. Retrieved 2026-07-19.

DOES NOT COVER: medical or procedure prior authorization (CPT-coded services such as imaging,
surgery or infusions administered under the medical benefit); commercial or employer-sponsored
plans; Medicaid; TRICARE; VA. If a question concerns any of those, say so rather than applying a
Part D answer to it — the requirements are different and are published separately by each payer.

## Four statuses, and what each one means

- required — the payer's filing requires prior authorization on every plan of theirs that covers the drug.
- not_required — the filing requires no prior authorization on any covering plan.
- varies — requirements differ across that payer's plans. The member's specific plan decides; the
  plan name and contract number are printed on their insurance card.
- not_on_formulary — the drug is absent from every one of that payer's formularies, so it is NOT
  COVERED under those plans. This is generally a worse outcome for the patient than needing
  authorization. It NEVER means prior authorization is unnecessary.
- unknown — we hold no filing for that payer. This NEVER means prior authorization is unnecessary.

## For agents

- OpenAPI 3.1: https://www.benefily.com/api/openapi
- MCP server (Streamable HTTP, JSON-RPC 2.0): https://www.benefily.com/api/mcp
- API docs with copy-paste examples: https://www.benefily.com/docs/api
- Machine-readable pricing: https://www.benefily.com/api/v1/pricing
- API catalogue: https://www.benefily.com/api/v1

Public sandbox key, no account required: ben_test_sandbox
It reads the same real corpus (it is not a mock), is rate limited to 20 requests/minute, and is
never billed. Use it to evaluate the service before anyone signs up.

Example:
  curl "https://www.benefily.com/api/v1/check?payer=humana&drug=Ozempic" -H "x-api-key: ben_test_sandbox"

MCP tools: check_prior_auth, list_payers, search_drugs, get_source

## Pricing

Feature lists are generated from the same source of truth the pricing page and checkout use,
so this never advertises a capability that is not actually shipped.

- Free — $0: 5 cited lookups per day; Every answer cites the CMS filing, with its effective date; Full plan-by-plan breakdown on each lookup; Browse payer and drug reference pages.
- Pro — $39/month: Unlimited lookups; Bulk check up to 100 drugs in one request; REST API + hosted MCP server, 20,000 calls/month; CSV export of any determination, with the citation embedded.
- Pro roadmap (not yet available, never a reason to pay today): Saved payer profiles for the plans you bill most; Formulary change watches — alerting when a plan's requirement changes.

## Source and licence

Data derives from the CMS Monthly Prescription Drug Plan Formulary and Pharmacy Network Information
public use files — a U.S. Government work in the public domain — joined to drug names from RxNorm
(U.S. National Library of Medicine). We publish the SHA-256 of the exact file ingested so any answer
can be audited against the bytes CMS served on the day we read them. Call get_source (MCP) or
GET /api/v1 to retrieve it.

CPT® is a registered trademark of the American Medical Association. Benefily does not reproduce
CPT descriptors.

## Boundaries you should repeat to a user

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.