Consumer Real-Time Pharmacy Benefit Check FHIR IG
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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

: RTPBC Formulary Status Code System

Page standards status: Trial-use Maturity Level: 4

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="rtpbc-formulary-status"/>
  <language value="en"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="phx"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
    <valueInteger value="4">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"/>
      </extension>
    </valueInteger>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status"/>
  <version value="2.0.0"/>
  <name value="RtpbcFormularyStatusCodeSystem"/>
  <title value="RTPBC Formulary Status Code System"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-10-03T00:00:00-05:00"/>
  <publisher value="HL7 International / Pharmacy"/>
  <contact>
    <name value="HL7 International / Pharmacy"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/medication"/>
    </telecom>
  </contact>
  <contact>
    <name value="Frank McKinney"/>
    <telecom>
      <system value="email"/>
      <value value="fm@frankmckinney.com"/>
    </telecom>
  </contact>
  <description
               value="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 value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <caseSensitive value="false"/>
  <content value="complete"/>
  <count value="9"/>
  <concept>
    <code value="B"/>
    <display value="Brand Preferred"/>
    <definition
                value="Indicates the payer prefers the brand over the generic"/>
  </concept>
  <concept>
    <code value="C"/>
    <display value="Carve-Out"/>
    <definition
                value="This medication is processed by a third party, not the payer providing the formulary"/>
  </concept>
  <concept>
    <code value="N"/>
    <display value="Non-Formulary"/>
    <definition
                value="Response code indicating that the prescribed drug is not included in the plan formulary"/>
  </concept>
  <concept>
    <code value="O"/>
    <display value="On Formulary"/>
    <definition
                value="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"/>
  </concept>
  <concept>
    <code value="P"/>
    <display value="On Formulary/Preferred"/>
    <definition
                value="The medication is the preferred payable products in that patient's plan formulary"/>
  </concept>
  <concept>
    <code value="U"/>
    <display value="Unknown"/>
    <definition value="Unknown"/>
  </concept>
  <concept>
    <code value="X"/>
    <display value="Non-Reimbursable without authorization"/>
    <definition
                value="This medication is not covered although an exception or appeal process may exist"/>
  </concept>
  <concept>
    <code value="Y"/>
    <display value="Non-Reimbursable"/>
    <definition
                value="The medication will never be reimbursable by the payer with no appeal process"/>
  </concept>
  <concept>
    <code value="Z"/>
    <display value="Zero Dollar Copay"/>
    <definition
                value="This medication does not have a copay. The cost is $0 to the patient"/>
  </concept>
</CodeSystem>