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

ValueSet: RTPBC Formulary Status Value Set

Official URL: http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-formulary-status Version: 2.0.0
Standards status: Trial-use Active as of 2025-10-03 Maturity Level: 4 Computable Name: RtbpcFormularyStatusValueSet

This value set contains formulary statuses that may apply to a prescription product evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.

References

Logical Definition (CLD)

 

Expansion

Expansion performed internally based on codesystem RTPBC Formulary Status Code System v2.0.0 (CodeSystem)

This value set contains 9 concepts

SystemCodeDisplay (en)DefinitionJSONXML
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  BBrand PreferredIndicates the payer prefers the brand over the generic
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  CCarve-OutThis medication is processed by a third party, not the payer providing the formulary
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  NNon-FormularyResponse code indicating that the prescribed drug is not included in the plan formulary
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  OOn FormularyThe 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
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  POn Formulary/PreferredThe medication is the preferred payable products in that patient's plan formulary
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  UUnknownUnknown
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  XNon-Reimbursable without authorizationThis medication is not covered although an exception or appeal process may exist
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  YNon-ReimbursableThe medication will never be reimbursable by the payer with no appeal process
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status  ZZero Dollar CopayThis medication does not have a copay. The cost is $0 to the patient

Description of the above table(s).