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coverage-exception

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.

Input Schema

TableJSON Schema
NameRequiredDescriptionDefault
drugYesBrand or generic drug name, e.g. "Humira", "adalimumab"
stateNoOptional 2-letter US state code, e.g. "TX"

Schema Changelog

Changes observed during successful MCP inspections.

  1. First observed

TDQS

A4.1/5.0
Behavior5/5

Does the description disclose side effects, auth requirements, rate limits, or destructive behavior?

No annotations are provided, so the description carries the full burden. It explicitly discloses that plan-specific clinical criteria and appeal deadlines are NOT held and are never inferred, and that they are returned in an explicit 'unavailable' block rather than guessed. It also discloses it returns per-plan flag counts across held plans, setting accurate expectations about output and limitations.

Agents need to know what a tool does to the world before calling it. Descriptions should go beyond structured annotations to explain consequences.

Conciseness4/5

Is the description appropriately sized, front-loaded, and free of redundancy?

Description is moderately long but information-dense, front-loading the primary purpose and specific outputs. The limitations clause is essential and placed at the end. No wasted words, though it could be tightened for brevity.

Shorter descriptions cost fewer tokens and are easier for agents to parse. Every sentence should earn its place.

Completeness4/5

Given the tool's complexity, does the description cover enough for an agent to succeed on first attempt?

Given no output schema and no annotations, the description covers the tool's main function, return type (per-plan counts, unavailable block), and key limitations. It lacks explicit response format but adequately equips an agent to invoke the tool for coverage-restriction/appeal queries.

Complex tools with many parameters or behaviors need more documentation. Simple tools need less. This dimension scales expectations accordingly.

Parameters3/5

Does the description clarify parameter syntax, constraints, interactions, or defaults beyond what the schema provides?

Schema description coverage is 100% (both parameters documented). The description adds contextual framing (e.g., drug and state for Medicare Part D plans) but does not provide extra semantics beyond the schema. Baseline 3 is appropriate for high schema coverage.

Input schemas describe structure but not intent. Descriptions should explain non-obvious parameter relationships and valid value ranges.

Purpose5/5

Does the description clearly state what the tool does and how it differs from similar tools?

States exactly what the tool does: names the coverage problem for a Part D drug (covered, prior authorization, step therapy, quantity limit, or not on formulary) and provides the exception/appeal path with CMS levels, requester, and questions for plan and prescriber. The explicit list of coverage problems and appeal elements clearly differentiates it from the sibling out-of-pocket cap tool.

Agents choose between tools based on descriptions. A clear purpose with a specific verb and resource helps agents select the right tool.

Usage Guidelines3/5

Does the description explain when to use this tool, when not to, or what alternatives exist?

Does not explicitly mention when to use this vs. the sibling medicare_part_d_out_of_pocket_cap. However, the description clearly implies it is for coverage restrictions and exceptions, not cost caps, so usage can be inferred. Lacks explicit when-not or alternative routing.

Agents often have multiple tools that could apply. Explicit usage guidance like "use X instead of Y when Z" prevents misuse.

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