Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build

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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## Home

Official URL: http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc | Version: 2.0.0
IG Standards status: Trial-use Active as of 2025-12-16 | Maturity Level: 4 | Computable Name: ConsumerRealTimePharmacyBenefitCheck

> The STU2 version of the Consumer RTPBC guide expands information that clients can retrieve from a patient's insurer and other data sources, provides additional guidance, and refines other aspects based on implementer feedback,

Where possible, new content is highlighted with green text and background. This highlighting will be removed prior to publication.

Sections with additions or adjustments are noted in yellow.

** To do: Add plain language description. **

### Overview

This section has be adjusted. Modifications are italicized.

This is a guide for implementing a consumer-focused Real-time Pharmacy Benefit Check (RTPBC) process using HL7 FHIR® R4.

Using RTPBC, a patient can learn the cost, insurance coverage and other information related to medications they've been prescribed. Specifically…

- how a medication will be covered by their insurance, including out of pocket costs and any coverage restrictions or requirements that might apply
- cash pricing and discounts available for the medication
- availability of financial assistance or other support.

Consumer RTPBC leverages the predetermination process supported by the Claim and ClaimResponse FHIR® resources. Accompanying resources carry information that identifies the patient and their insurance coverage, prescription information and the preferred pharmacy (Patient, Coverage, MedicationRequest, Practitioner and Organization). OperationOutcome is used to communicate exceptions.

Where possible, the profile leverages terminology currently used in US pharmacy benefit processing, to minimize implementation obstacles for stakeholders who operate in that domain.

### Scope of this guide

Consumer RTPBC is intended to be used…

- in the United States (as it reflects unique US pharmacy insurance roles and conventions)
- for medications that are covered under the pharmacy benefit portion of the patient's health insurance, which typically excludes medications administered during hospital care or as part of medical procedures
- for commercially available medication products that are not compounded at the pharmacy. (Support for compounds could potentially be added later)

Relationship to the NCPDP provider-focused RTPBC transactions

This section has be adjusted. Modifications are italicized.

The consumer RTPBC profile seeks to provide a patients with coverage and cost information that's consistent with information made available to their provider through the NCPDP Real Time Prescription Benefit (RTPB) standard.

Because this specification focuses on what's most useful and meaningful to patients, certain content in the provider-centric NCPDP RTPBC standard is not included here. (See Consumer vs provider RTPBC for a content comparison.)

Related information flows outside of consumer RTPBC

The patient application might gather related information before submitting the consumer RTPBC request, such as prescription information or insurance eligibility. These exchanges are outside the scope of this guide.

Support for addresses outside the US

This implementation guide supports military and Canadian addresses for patients and pharmacies, in order to be consistent with other US pharmacy benefit processes. Specifically, the guide enables use of Canada province codes and military 'state' codes (e.g., AE for Armed Forces Europe).

### Content and Organization

This section is new in STU2

The guide is organized into the following sections:

- ​Use Case Overview describes the RTPBC use case, participants and high-level exchange flows.
- Information Content describes what's in the RTPBC request and response.
- Business Rules highlights non-technical content and behavior expectations for requesters and responders.
- Submission Method provides key points about the IG's use of FHIR messaging.
- Error Handling sets expectations on reporting technical and business response errors.
- ​Mappings to Related Standards describes how FHIR content relates to other standards use in the larger PDMP ecosystem.
- Security provides direction on use of SMART on FHIR to secure RTPBC exchanges.
- Provider vs Consumer RTPBC provides a comparison of this guide to provider-facing messaging defined in the NCPDP RTPB standard.
- Artifacts contains the FHIR profiles and other artifacts defined in this IG.

### Authors

HL7 Pharmacy Workgroup |
HL7 Financial Management Workgroup |
Frank McKinney | fm@frankmckinney.com

### Dependencies

IG | Package | FHIR | Comment
--- | --- | --- | ---
Consumer Real-Time Pharmacy Benefit Check FHIR IG | hl7.fhir.us.carin-rtpbc#2.0.0 | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#7.0.1 | R4 | Automatically added as a dependency - all IGs depend on HL7 Terminology
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#5.2.0 | R4 |
US Core Implementation Guide | hl7.fhir.us.core#8.0.1 | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#7.0.0 | R4 |
SMART App Launch | hl7.fhir.uv.smart-app-launch#2.2.0 | R4 |
HL7 Terminology (THO) | hl7.terminology#5.5.0 | R4 |
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#1.0.0 | R4 |
VSAC | us.nlm.vsac#0.24.0 | R4 |
Structured Data Capture | hl7.fhir.uv.sdc#3.0.0 | R4 |
PHINVads | us.cdc.phinvads#0.12.0 | R4 |
FHIR Tooling Extensions IG | hl7.fhir.uv.tools.r4#0.8.0 | R4 | for example references

Package hl7.fhir.uv.extensions.r4#5.2.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Mon, Feb 10, 2025 21:45+1100+11:00)

Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00)

Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. This includes two components: * Support more sophisticated questionnaire/form use-cases such as those needed for research, oncology, pathology and other clinical domains. *Support pre-population and auto-population of EHR data into forms/questionnaires for uses outside direct clinical care (patient safety, adverse event reporting, public health reporting, etc.). (built Tue, Mar 8, 2022 18:32+0000+00:00)

Package hl7.fhir.us.core#8.0.1 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Wed, Dec 10, 2025 03:47+0500+05:00)

Package hl7.fhir.uv.tools.r4#0.8.0 This IG defines the extensions that the tools use internally. Some of these extensions are content that are being evaluated for elevation into the main spec, and others are tooling concerns (built Tue, Aug 5, 2025 20:09+1000+10:00)

### Cross Version Analysis

This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (hl7.fhir.us.carin-rtpbc.r4) and R4B (hl7.fhir.us.carin-rtpbc.r4b) are available.

### Global Profiles

There are no Global profiles defined

### IP Statements

This publication includes IP covered under the following statements.

- ISO maintains the copyright on the country codes, and controls its use carefully. For further details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
  Show Usage
  - ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code: ConsumerRealTimePharmacyBenefitCheck, RTPBCPrescribableProductCodeValueSet... Show 36 more, RtbpcBenefitRestrictionValueSet, RtbpcBillingUnitValueSet, RtbpcErrorCodeValueSet, RtbpcEventTypeValueSet, RtbpcFormularyStatusValueSet, RtbpcPatientPayTypeValueSet, RtpbcBenefitRestrictionCodeSystem, RtpbcCountryCodeValueSet, RtpbcCoverage, RtpbcEventTypeCodeSystem, RtpbcExtensionBenefitRestriction, RtpbcExtensionFormularyStatus, RtpbcExtensionNextAvailableFillDate, RtpbcExtensionPreferenceLevel, RtpbcFormularyStatusCodeSystem, RtpbcIsAlternativeExtension, RtpbcMedicationRequest, RtpbcMedicationRequestNonPHI, RtpbcPatient, RtpbcPatientNonPHI, RtpbcPatientPayTypeCodeSystem, RtpbcPharmacy, RtpbcPharmacyTypeValueSet, RtpbcRequest, RtpbcRequestBundle, RtpbcRequestBundleNonPHI, RtpbcRequestClaim, RtpbcRequestClaimNonPHI, RtpbcRequestMessageHeader, RtpbcRequesterCapabilityStatement, RtpbcResponderCapabilityStatement, RtpbcResponse, RtpbcResponseBundle, RtpbcResponseClaimResponse, RtpbcResponseMessageHeader and RtpbcStateAndProvinceCodeValueSet
- The UCUM codes, UCUM table (regardless of format), and UCUM Specification are copyright 1999-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. https://ucum.org/trac/wiki/TermsOfUse
  Show Usage
  - Unified Code for Units of Measure (UCUM): RtbpcBillingUnitValueSet, RtpbcMedicationRequest... Show 4 more, RtpbcMedicationRequestNonPHI, RtpbcRequestClaim, RtpbcRequestClaimNonPHI and RtpbcResponseClaimResponse
- This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
  Show Usage
  - Claim Type Codes: Bundle/rtpbc-bundle-request-03, Bundle/rtpbc-bundle-request-non-phi-1... Show 10 more, Bundle/rtpbc-bundle-request-non-phi-2, Bundle/rtpbc-bundle-request-price-source, Bundle/rtpbc-bundle-response-03, Bundle/rtpbc-bundle-response-price-source, Claim/rtpbc-claim-03, Claim/rtpbc-claim-non-phi-1, Claim/rtpbc-claim-non-phi-2, ClaimResponse/rtpbc-claim-response-03, ClaimResponse/rtpbc-claim-response-03-price-source and ClaimResponse/rtpbc-claim-response-not-covered
  - Coverage Class Codes: Bundle/rtpbc-bundle-request-03, Coverage/rtpbc-coverage-01 and RtpbcCoverage
  - Process Priority Codes: Bundle/rtpbc-bundle-request-03, Bundle/rtpbc-bundle-request-non-phi-1... Show 5 more, Bundle/rtpbc-bundle-request-non-phi-2, Bundle/rtpbc-bundle-request-price-source, Claim/rtpbc-claim-03, Claim/rtpbc-claim-non-phi-1 and Claim/rtpbc-claim-non-phi-2
  - SubscriberPolicyholder Relationship Codes: Bundle/rtpbc-bundle-request-03 and Coverage/rtpbc-coverage-01
  - identifierType: Bundle/rtpbc-bundle-request-03, Bundle/rtpbc-bundle-request-price-source... Show 5 more, Bundle/rtpbc-bundle-response-03, Bundle/rtpbc-bundle-response-price-source, Patient/rtpbc-patient-03, Patient/rtpbc-patient-03ps and RtpbcCoverage
- Using RxNorm codes of type SAB=RXNORM as this specification describes does not require a UMLS license. Access to the full set of RxNorm definitions, and/or additional use of other RxNorm structures and information requires a UMLS license. The use of RxNorm in this specification is pursuant to HL7's status as a licensee of the NLM UMLS. HL7's license does not convey the right to use RxNorm to any users of this specification; implementers must acquire a license to use RxNorm in their own right.
  Show Usage
  - RxNorm: Bundle/rtpbc-bundle-request-03, Bundle/rtpbc-bundle-request-price-source... Show 13 more, Bundle/rtpbc-bundle-response-03, Bundle/rtpbc-bundle-response-price-source, Claim/rtpbc-claim-03, ClaimResponse/rtpbc-claim-response-03, ClaimResponse/rtpbc-claim-response-03-price-source, ClaimResponse/rtpbc-claim-response-not-covered, MedicationRequest/rtpbc-medicationrequest-03, RTPBCPrescribableProductCodeValueSet, RtpbcMedicationRequest, RtpbcMedicationRequestNonPHI, RtpbcRequestClaim, RtpbcRequestClaimNonPHI and RtpbcResponseClaimResponse

### Expansion Parameters

Parameter | Value
--- | ---
system-version | SNOMED CT[US]