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

## : RTPBC Formulary Status Code System

Page standards status: Trial-use | Maturity Level: 4

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

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