Overview - Simplex

The Prior Auth SDK is a high-level wrapper around the Simplex Prior Auth API. It resolves payer clinical question sets, fills fax PA forms, and transmits them — all without you having to know which line of business a patient’s BIN/PCN maps to.

Installation

Python
TypeScript

pip install simplex

npm install simplex-ts

Quick Start

The minimal fax-PA workflow is two calls: resolve the canonical drug string, then pull the payer-specific clinical question set for that drug and diagnosis.

1. Search drugs

Resolve a free-text query (e.g. "wegovy 1mg") into the canonical Brand Strength Form string expected by drug_info.medication_strength on Fill Prior Authorization. The supported catalog currently covers Wegovy, Ozempic, Zepbound, and Mounjaro (all SKUs).

Python
TypeScript

from simplex import SimplexClient

client = SimplexClient()

matches = client.search_drugs(query="wegovy 1mg")
for m in matches:
    print(m["full_name"])

import { SimplexClient } from "simplex-ts";

const client = new SimplexClient();

const matches = await client.searchDrugs({ query: "wegovy 1mg" });
for (const m of matches) {
  console.log(m.fullName);
}

2. Get clinical questions

Pass the pharmacy claim’s (bin, state, drug_name, icd_code) tuple to pin down the line of business and indication. pcn, group_id, and member_id are optional tiebreakers for shared-processor BINs (e.g. BIN 003858 / PCN A4 hosts both ESI Commercial and Humana Part D — the leading alpha prefix of member_id disambiguates). Each returned question carries a structured citation back to the underlying payer policy (URL, policy ID, section, verbatim quote), so you can show reviewers the source.

Python
TypeScript

from simplex import SimplexClient, SimplexError

client = SimplexClient()

try:
    response = client.get_clinical_questions(
        bin="003858",
        state="CA",
        drug_name="wegovy",
        icd_code="E66.01",
        pcn="A4",
        member_id="4XS1234567",
    )

    print("matched:", response.get("matched"))
    print("coverage_status:", response.get("coverage_status"))
    print("lob_id:", response.get("lob_id"))

    routing = response.get("routing") or {}
    print(f"PBM: {routing.get('pbm_name')}")
    print(f"LOB: {routing.get('line_of_business')}")
    print(f"Plan/Group: {routing.get('plan_name_or_group')}")
    print(f"Confidence: {routing.get('confidence')}")

    for i, q in enumerate(response.get("questions") or [], 1):
        req = "required" if q.get("required") else "optional"
        print(f"{i}. [{q.get('input_type')}, {req}] {q.get('prompt')}")
        citation = q.get("citation")
        if citation:
            print(
                f"   ↳ {citation.get('policy_id')} "
                f"§{citation.get('section')} "
                f"({citation.get('effective_date')})"
            )
except SimplexError as e:
    print(f"Simplex error: {e}")

import { SimplexClient, SimplexError } from "simplex-ts";

const client = new SimplexClient();

try {
  const response = await client.getClinicalQuestions({
    bin: "003858",
    state: "CA",
    drugName: "wegovy",
    icdCode: "E66.01",
    pcn: "A4",
    memberId: "4XS1234567",
  });

  console.log("matched:", response.matched);
  console.log("coverage_status:", response.coverageStatus);
  console.log("lob_id:", response.lobId);

  const { routing } = response;
  console.log(`PBM: ${routing?.pbmName}`);
  console.log(`LOB: ${routing?.lineOfBusiness}`);
  console.log(`Plan/Group: ${routing?.planNameOrGroup}`);
  console.log(`Confidence: ${routing?.confidence}`);

  (response.questions ?? []).forEach((q, i) => {
    const req = q.required ? "required" : "optional";
    console.log(`${i + 1}. [${q.inputType}, ${req}] ${q.prompt}`);
    if (q.citation) {
      console.log(
        `   ↳ ${q.citation.policyId} §${q.citation.section} ` +
          `(${q.citation.effectiveDate})`
      );
    }
  });
} catch (e) {
  if (e instanceof SimplexError) {
    console.error(`Simplex error: ${e.message}`);
  }
}

Next steps

Fill Prior Authorization — fill a fax PA form with the patient/prescriber/drug data plus answers to the clinical questions returned above
Submit Prior Authorization — transmit the filled form to the payer
Check Status — poll a submitted PA for its current status

​Installation

​Quick Start

​1. Search drugs

​2. Get clinical questions

​Next steps

Installation

Quick Start

1. Search drugs

2. Get clinical questions

Next steps