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

## Example ClaimResponse: rtpbc-claim-response-not-covered

Page standards status: Informative

### RTPBC ClaimResponse - requested drug is not covered

In this example:

- the requested medication is not covered by the patient's plan. The Benefit Restriction contains a value of "not-covered" and the adjucation shows an eligible amount of zero dollars.
- the addItem contains an alternative drug that is covered, but with a requirement for prior authorziation and a quantity limit. Details of the quantity limit are conveyed in the processNote element.

Language: en

Profile: RTPBC Response Using ClaimResponse

identifier: rtpbc-03-response-c-r

status: Active

type: Pharmacy

use: Predetermination

patient: Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)

created: 2019-11-01 11:20:59-0500

insurer: Identifier: Pharmacy Plans US

request: Identifier: rtpbc-03

outcome: Processing Complete

disposition: Processed successfully

> item

> RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System: not-covered (Not covered)

> itemSequence: 1

> > adjudication

> > category: Eligible amount

> > ### Amounts

> > - | Value | Currency
> > * | 0 | United States dollar

> addItem

> RTPBC isAlternative Extension: true

> RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System: prior-auth (Prior authorization required)

> RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System: quantity-limit (Quantity limit applies)

> itemSequence: 1

> provider: Organization My Mail Service Pharmacy

> productOrService: elbasvir 50 MG / grazoprevir 100 MG Oral Tablet [Zepatier]

> quantity: 28 {Each}

> noteNumber: 1

> > adjudication

> > category: Copay

> > ### Amounts

> > - | Value | Currency
> > * | 405 | United States dollar

> > adjudication

> > category: Per prescription coinsurance

> > ### Amounts

> > - | Value | Currency
> > * | 469 | United States dollar

> > adjudication

> > category: Total patient responsibility

> > ### Amounts

> > - | Value | Currency
> > * | 874 | United States dollar

### ProcessNotes

- | Number | Text
* | 1 | Quantity limit: 28 tablets per month