# Unofficial Medicaid MCP Server
> Model Context Protocol (MCP) server for Medicaid public data access via data.medicaid.gov and state formularies
## Features
### State Formulary Coverage
Access Medicaid formularies for 5 states covering 43% of US Medicaid beneficiaries (32M of 74M):
- **California** - 40K drugs with NDC codes, prior authorization requirements, tier-based pricing
- **New York** - 37K drugs with MRA pricing, daily updates, preferred drug lists
- **Ohio** - 76K drugs with comprehensive step therapy and quantity limit data
- **Texas** - 4.7K drugs with multi-program pricing (Medicaid, CHIP, specialty programs)
- **Illinois** - 5.7K drugs with intelligent cross-state NDC enrichment (61.7% coverage)
### Pricing & Utilization Data
- **NADAC Drug Pricing** - National average drug acquisition costs (1.5M NDCs, weekly updates)
- **Federal Upper Limits** - Generic drug maximum reimbursement (2.1M records, monthly updates)
- **Drug Rebate Program** - Manufacturer product information and rebate agreements (~3M records)
- **State Drug Utilization** - Prescription volume by state, drug, and quarter (5.3M records)
- **Enrollment Trends** - Monthly Medicaid/CHIP enrollment by state (all 50 states + territories)
### Technical Features
- **Hybrid Architecture** - Optimized data access: in-memory caching for small datasets, streaming API for large datasets
- **Automatic Pricing Integration** - Formulary queries auto-enrich with NADAC pricing data
- **Intelligent Enrichment** - Illinois formulary enhanced via cross-state NDC matching (CA/NY/OH sources)
## Usage
```json
{
"mcpServers": {
"medicaid": {
"command": "node",
"args": ["/path/to/medicaid-mcp-server/build/index.js"]
}
}
}
```
## API Reference
### Unified Tool: `medicaid_info`
The server provides a single tool with multiple methods:
#### State Formulary Search
```javascript
{
"method": "search_state_formulary",
"state": "CA", // CA, NY, OH, TX, IL
"label_name": "OZEMPIC",
"limit": 10
}
```
**Parameters:**
- `state` (required): State code (CA, NY, OH, TX, IL)
- `label_name`: Brand/trade name
- `generic_name`: Generic drug name
- `ndc`: 11-digit NDC code
- `requires_pa`: Prior authorization filter (true/false)
- `has_ndc`: Filter for drugs with NDC codes (Illinois only)
- `limit`: Max results (default: 10)
**State-Specific Parameters:**
California:
- `tier`: Cost ceiling tier ("Brand" or "Generic")
- `extended_duration`: Extended duration eligibility (true/false)
Texas:
- `pdl_pa`: PDL prior authorization (true/false)
- `clinical_pa`: Clinical prior authorization (true/false)
- `program`: Program filter (medicaid, chip, cshcn, etc.)
- `max_price` / `min_price`: Price range filters
New York:
- `preferred`: Preferred drug status (true/false)
- `is_brand`: Brand vs generic filter (true/false)
- `max_price` / `min_price`: MRA cost range
#### Drug Pricing
```javascript
{
"method": "get_nadac_pricing",
"drug_name": "ibuprofen",
"limit": 10
}
```
**Parameters:**
- `drug_name`: Drug name (fuzzy match)
- `ndc`: Specific 11-digit NDC code
- `limit`: Max results (default: 10)
#### Enrollment Trends
```javascript
{
"method": "get_enrollment_trends",
"state": "CA",
"start_date": "2023-01-01",
"end_date": "2024-12-31"
}
```
#### Federal Upper Limits
```javascript
{
"method": "get_federal_upper_limits",
"ingredient": "NYSTATIN",
"limit": 10
}
```
#### Drug Rebate Information
```javascript
{
"method": "get_drug_rebate_info",
"drug_name": "ozempic", // or labeler_name: "novo nordisk"
"limit": 10
}
```
#### State Drug Utilization
```javascript
{
"method": "get_drug_utilization",
"state": "CA",
"drug_name": "OZEMPIC",
"year": 2024,
"quarter": 4,
"limit": 10
}
```
## Architecture
The server uses a hybrid data access strategy optimized for performance and memory efficiency:
**Cached Datasets** - Small, frequently accessed data loaded into memory:
- State formularies (CA, NY, OH, TX, IL) - Excel/CSV/JSON/Text parsing with TTL-based refresh
- NADAC pricing (123 MB) - Weekly CSV download, cached for fast lookups
- State enrollment (3.6 MB) - Monthly snapshots, cached for trend analysis
**Streaming API** - Large datasets queried on-demand via CMS DKAN API:
- Federal Upper Limits (196 MB, 2.1M records)
- Drug Rebate Program (291 MB, ~3M records)
- State Drug Utilization (192 MB, 5.3M records)
**Memory Footprint**: ~215 MB total for cached datasets, minimal for API queries
### Performance Characteristics
| Dataset | Access Method | Typical Response Time |
|---------|---------------|----------------------|
| State Formularies | In-memory cache | <100ms |
| NADAC Pricing | In-memory cache | <100ms (20-30s initial load) |
| State Enrollment | In-memory cache | <50ms |
| Federal Upper Limits | DKAN API streaming | 1-2s |
| Drug Rebate Program | DKAN API streaming | 1-2s |
| State Drug Utilization | DKAN API streaming | 1-2s |
## Data Sources
| Dataset | Update Frequency | Coverage | Authority |
|---------|-----------------|----------|-----------|
| NADAC | Weekly | 1.5M NDC codes | CMS |
| State Formularies | Daily-Monthly | 43% of US Medicaid | State agencies |
| Federal Upper Limits | Monthly | 2.1M records | CMS |
| Drug Rebate | Quarterly | ~3M records | CMS |
| Drug Utilization | Quarterly | 5.3M records | CMS |
| Enrollment | Monthly | All states | CMS |
## Query Examples
### State Formulary Search with Automatic Pricing
```javascript
// Find GLP-1 drugs in California
{
"method": "search_state_formulary",
"state": "CA",
"generic_name": "semaglutide",
"limit": 10
}
// Returns formulary data with automatic NADAC pricing integration
```
### Multi-State Enrollment Comparison
```javascript
{
"method": "compare_state_enrollment",
"states": ["CA", "TX", "NY", "FL"],
"month": "2024-09"
}
```
### Cross-State NDC Enrichment
```javascript
// Illinois formulary with intelligent enrichment
{
"method": "search_state_formulary",
"state": "IL",
"label_name": "OZEMPIC",
"limit": 10
}
// Returns IL formulary enriched with NDC codes from CA/NY/OH (61.7% coverage)
```
## Use Cases
**Market Access & Strategy**
- State formulary coverage analysis and prioritization
- Prior authorization landscape mapping
- Competitive tier placement assessment
**Pricing Intelligence**
- NADAC price trend analysis and forecasting
- Multi-state pricing comparisons
- Rebate program eligibility verification
**Policy & Economics**
- Medicaid expansion impact analysis
- State enrollment forecasting and growth trends
- Utilization pattern analysis by geography
**Limitations**
- Provider-level utilization data not available (use Medicare MCP for provider analytics)
- Individual beneficiary claims require CMS Data Use Agreement (T-MSIS/TAF)
- No HCPCS procedure-level analysis (state-level aggregate data only)
