specification: API Commons Plans
specificationVersion: '0.1'
schema: https://raw.githubusercontent.com/api-evangelist/interface-research/main/schema/api-commons.yml#/$defs/Plans
provider: AmeriHealth Caritas
providerId: amerihealth-caritas
created: '2026-05-23'
modified: '2026-05-23'
reconciled: true
tags:
  - FHIR
  - Healthcare
  - Health Insurance
  - Medicaid
  - Interoperability
  - CMS
  - Patient Access
  - Provider Directory
  - Drug Formulary
description: >-
  AmeriHealth Caritas exposes HL7 FHIR R4 APIs (Patient Access, Provider
  Directory, Drug Formulary) to satisfy the CMS Interoperability and
  Patient Access final rule (CMS-9115-F). The APIs are free to
  registered third-party applications: access is governed by SMART on
  FHIR / OAuth 2.0, member consent, and a CMS-aligned attestation rather
  than a commercial price tier. There is no list price, no metered rate
  card, and no paid subscription. Member health-plan products (Medicaid,
  CHIP, D-SNP, LTSS, Marketplace) are sold through state Medicaid
  agencies, CMS, and state Marketplaces and are out of scope for an API
  pricing surface.
notes: >-
  APIs are provided pursuant to CMS interoperability mandates; no
  commercial pricing exists. Plan entries describe the free regulatory
  access surface rather than dollar-denominated tiers. Plan-side
  insurance pricing (member premiums, copays, deductibles) is set per
  state plan and is not part of this API plans file.
sources:
  - https://developer.amerihealthcaritas.com/
  - https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/
  - https://www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability
  - https://www.amerihealthcaritas.com/find-a-health-plan
plans:
  - id: ahc-developer-sandbox
    name: Developer Sandbox
    type: freemium
    description: >-
      Free sandbox access for testing against synthetic patient data,
      the live FHIR CapabilityStatements, and the per-plan FHIR
      endpoints. Sandbox member credentials are issued to registered
      developers after account activation.
    entries:
      - label: Sandbox FHIR requests
        name: sandbox_requests
        type: flat
        metric: request
        limit: -1
        timeFrame: usage
        geo: US
        unit: 1
        price: '0.00'
        userMultiplied: false
    elements:
      - name: FHIR R4 sandbox endpoints (Patient Access & Provider Directory)
      - name: Synthetic patient credentials issued to registered developers
      - name: Live CapabilityStatements per plan code
      - name: SMART App Launch / OAuth 2.0 / PKCE test flows
      - name: No commercial cost
  - id: ahc-production-patient-access
    name: CMS Patient Access (Production)
    type: freemium
    description: >-
      Production access for third-party member-facing apps under CMS-
      9115-F. Requires developer registration, app attestation, and
      SMART on FHIR / OAuth 2.0 with member consent. No fees are
      charged to the application or member.
    entries:
      - label: Patient Access FHIR requests
        name: patient_access_requests
        type: flat
        metric: request
        limit: -1
        timeFrame: usage
        geo: US
        unit: 1
        price: '0.00'
        userMultiplied: false
    elements:
      - name: SMART on FHIR / OAuth 2.0 + PKCE member consent
      - name: Per-plan FHIR endpoint routing (0100, 0500, 0900, 2400, 2600)
      - name: AllergyIntolerance, Claim, Condition, Coverage, Encounter, ExplanationOfBenefit
      - name: Immunization, Medication, MedicationDispense, MedicationKnowledge, MedicationRequest
      - name: Observation, Organization, OrganizationAffiliation, Patient, Practitioner, PractitionerRole, Procedure
      - name: Required developer attestation; HIPAA-aligned data handling
  - id: ahc-provider-directory
    name: Provider Directory (Public)
    type: freemium
    description: >-
      CMS-mandated public Provider Directory FHIR API. No
      authentication required. Suitable for cached integration into
      member-facing care navigation, broker tools, and benefits
      lookups.
    entries:
      - label: Provider Directory requests
        name: provider_directory_requests
        type: flat
        metric: request
        limit: -1
        timeFrame: usage
        geo: US
        unit: 1
        price: '0.00'
        userMultiplied: false
    elements:
      - name: Practitioner, PractitionerRole, Organization, OrganizationAffiliation, Location, InsurancePlan
      - name: Per-plan endpoints (0100, 0500, 0900, 1200, 2100, 2400, 2600)
      - name: No authentication required
  - id: ahc-drug-formulary
    name: Drug Formulary (Public)
    type: freemium
    description: >-
      CMS-mandated public Drug Formulary surface listing covered
      medications, tiering, and prior authorization indicators.
      Documented as a no-authentication surface in the developer
      portal; formulary content is currently navigable through FHIR
      MedicationKnowledge / List resources.
    entries:
      - label: Formulary requests
        name: formulary_requests
        type: flat
        metric: request
        limit: -1
        timeFrame: usage
        geo: US
        unit: 1
        price: '0.00'
        userMultiplied: false
    elements:
      - name: MedicationKnowledge, List resources
      - name: Drug formulary tiers and prior-authorization indicators
      - name: No authentication required
maintainers:
  - FN: Kin Lane
    email: kin@apievangelist.com