Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions

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: RTPBC Formulary Status Code System

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{
  "resourceType" : "CodeSystem",
  "id" : "rtpbc-formulary-status",
  "language" : "en",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem rtpbc-formulary-status</b></p><a name=\"rtpbc-formulary-status\"> </a><a name=\"hcrtpbc-formulary-status\"> </a><p>This case-insensitive code system <code>http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">B<a name=\"rtpbc-formulary-status-B\"> </a></td><td>Brand Preferred</td><td>Indicates the payer prefers the brand over the generic</td></tr><tr><td style=\"white-space:nowrap\">C<a name=\"rtpbc-formulary-status-C\"> </a></td><td>Carve-Out</td><td>This medication is processed by a third party, not the payer providing the formulary</td></tr><tr><td style=\"white-space:nowrap\">N<a name=\"rtpbc-formulary-status-N\"> </a></td><td>Non-Formulary</td><td>Response code indicating that the prescribed drug is not included in the plan formulary</td></tr><tr><td style=\"white-space:nowrap\">O<a name=\"rtpbc-formulary-status-O\"> </a></td><td>On Formulary</td><td>The medication submitted is included in the list of payable products in that patient's plan formulary but that there may be a more preferred product in the therapeutic category</td></tr><tr><td style=\"white-space:nowrap\">P<a name=\"rtpbc-formulary-status-P\"> </a></td><td>On Formulary/Preferred</td><td>The medication is the preferred payable products in that patient's plan formulary</td></tr><tr><td style=\"white-space:nowrap\">U<a name=\"rtpbc-formulary-status-U\"> </a></td><td>Unknown</td><td>Unknown</td></tr><tr><td style=\"white-space:nowrap\">X<a name=\"rtpbc-formulary-status-X\"> </a></td><td>Non-Reimbursable without authorization</td><td>This medication is not covered although an exception or appeal process may exist</td></tr><tr><td style=\"white-space:nowrap\">Y<a name=\"rtpbc-formulary-status-Y\"> </a></td><td>Non-Reimbursable</td><td>The medication will never be reimbursable by the payer with no appeal process</td></tr><tr><td style=\"white-space:nowrap\">Z<a name=\"rtpbc-formulary-status-Z\"> </a></td><td>Zero Dollar Copay</td><td>This medication does not have a copay. The cost is $0 to the patient</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "phx"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 4,
      "_valueInteger" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status",
  "version" : "2.0.0",
  "name" : "RtpbcFormularyStatusCodeSystem",
  "title" : "RTPBC Formulary Status Code System",
  "status" : "active",
  "experimental" : false,
  "date" : "2025-10-03T00:00:00-05:00",
  "publisher" : "HL7 International / Pharmacy",
  "contact" : [
    {
      "name" : "HL7 International / Pharmacy",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/medication"
        }
      ]
    },
    {
      "name" : "Frank McKinney",
      "telecom" : [
        {
          "system" : "email",
          "value" : "fm@frankmckinney.com"
        }
      ]
    }
  ],
  "description" : "This code system defines formulary statuses that may apply to a prescription product evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "caseSensitive" : false,
  "content" : "complete",
  "count" : 9,
  "concept" : [
    {
      "code" : "B",
      "display" : "Brand Preferred",
      "definition" : "Indicates the payer prefers the brand over the generic"
    },
    {
      "code" : "C",
      "display" : "Carve-Out",
      "definition" : "This medication is processed by a third party, not the payer providing the formulary"
    },
    {
      "code" : "N",
      "display" : "Non-Formulary",
      "definition" : "Response code indicating that the prescribed drug is not included in the plan formulary"
    },
    {
      "code" : "O",
      "display" : "On Formulary",
      "definition" : "The medication submitted is included in the list of payable products in that patient's plan formulary but that there may be a more preferred product in the therapeutic category"
    },
    {
      "code" : "P",
      "display" : "On Formulary/Preferred",
      "definition" : "The medication is the preferred payable products in that patient's plan formulary"
    },
    {
      "code" : "U",
      "display" : "Unknown",
      "definition" : "Unknown"
    },
    {
      "code" : "X",
      "display" : "Non-Reimbursable without authorization",
      "definition" : "This medication is not covered although an exception or appeal process may exist"
    },
    {
      "code" : "Y",
      "display" : "Non-Reimbursable",
      "definition" : "The medication will never be reimbursable by the payer with no appeal process"
    },
    {
      "code" : "Z",
      "display" : "Zero Dollar Copay",
      "definition" : "This medication does not have a copay. The cost is $0 to the patient"
    }
  ]
}