This CapabilityStatement describes the expected capabilities of a client system submitting a Real-time Pharmacy Benefit Check (RTPBC) request using the $process-message operation.

This CapabilityStatement describes the expected capabilities of a server that is capable of responding to a Real-time Pharmacy Benefit Check (RTPBC) request transacted with the $process-message operation.

Request for patient cost and coverage information for a prescribed medication

Response to a request for patient cost and coverage information for a prescribed medication

This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process

This profile constrains the MedicationRequest resource to convey a subset of prescription information required in the consumer real-time pharmacy benefit check (RTPBC) process. The content specifies the prescribed product and quantity, and references the prescribing practitioner and the patient's preferred pharmacy.

This profile differs from the US Core MedicationRequest in that it doesn't set the encounter or dosageInstruction elements as Must Support, because clients in the exchange will typically be mobile consumer applications that do not posess this information, and because that information is not pertinent to this use case.

This profile provides minimal prescription characteristics for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.

This profile constrains the Patient resource for carrying the limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process.

The RTPBC profile further constrains certain US Core and base elements in a manner that is compatible with the the US Core profile (e.g., tightening element cardinality and further limiting allowed terminology).

This profile provides minimal, non-persoanlly-identifiable patient characteristics for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.

This profile builds on the US Core Organization to represent a pharmacy as used in the real-time pharmacy benefit check (RTPBC) process.

This profile constrains a Bundle resource for use as the request in a Real-time Pharmacy Benefit Check (RTPBC) process

This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.

This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) request bundle

This profile constrains the Claim resource so that it can serve as the RTPBC Request in the consumer real-time pharmacy benefit check process

This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.

This profile constrains a Bundle resource for use as the response in a Real-time Pharmacy Benefit Check (RTPBC) process

This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) response bundle

This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process. It uses the ClaimResponse's "predetermination" processing mode

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This extension conveys the formulary status of a prescription product.

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service.

This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.

This extension conveys the preference level of a prescription product.

This value set contains a set of benefit restrictions that may apply to a prescription product and pharmacy combination evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.

This value set contains the quantity unit of measure to be used when requesting predetermination of benefits for prescription-related products

This value set contains a subset of two-letter ISO 3166-1-2 country codes for the countries in which this profile is intended to be used (US and CA).

This value set contains the error codes to be used by real-time pharmacy benefit check servers when encountering a data or business condition that prevents processing from completing. Values are defined in the NCPDP-maintained Reject Code (511-FB) code set.

This value set contains event types used in RTPBC message headers.

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

This value set contains components of a patient's responsibility for a prescription product's cost.

This value set contains pharmacy type categories defined in the NCPDP Pharmacy Type (955-HR) code system.

This value set includes codes used to specify prescribed medications in the US: RxNorm codes that specify drug name, strength and dose form (SBD, SCD, BPCK and GPCK term types) and NDC-11 codes (which represent specific packaged products).

This value set contains two letter USPS state codes and Canada Post province codes.

This code system defines a set of benefit restrictions that may apply to a prescription product and pharmacy combination evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.

This code system defines event types used in RTPBC message headers

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

This code system defines components of a patient's responsibility for a prescription product's cost.

An example RTPBC Request

An example non-PHI RTPBC Request

An example non-PHI RTPBC Request that omits the Patient resource

An example RTPBC request bundle

An example RTPBC response bundle produced by the patient's insurer

An example RTPBC response bundle produced by cash pricing source

An example of the primary RTPBC request resource (Claim)

An example of the non-PHI RTPBC request resource (Claim)

An example of the non-PHI RTPBC request resource (Claim) that doesn't reference a Patient resource

An example RTPBC response indicating PA is required and providing patient out-of-pocket costs

An example response from a cash pricing source

This is an example of response stating that the requested drug is not covered

An example RTPBC Coverage

An example RTPBC MedicationRequest

An example non-PHI RTPBC MedicationRequest

An example non-PHI RTPBC MedicationRequest

An example RTPBC pharmacy (Organization), representing a retail pharmacy

An example RTPBC pharmacy (FHIR Organization) representing a mail order pharmacy

An example retail pharmacy identified using an NCPDP Provider ID

An example RTPBC patient

An example RTPBC patient with minimal content

An example non-PHI RTPBC patient

An example, minimally-populated US Core Practitioner included in RTPBC examples