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

## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

RTPBC Requester Capability Statement | This CapabilityStatement describes the expected capabilities of a client system submitting a Real-time Pharmacy Benefit Check (RTPBC) request using the `$process-message` operation.
RTPBC Responder Capability Statement | This CapabilityStatement describes the expected capabilities of a server that is capable of responding to a Real-time Pharmacy Benefit Check (RTPBC) request transacted with the `$process-message` operation.

### Behavior: Message Definitions

These define the types of messages that can be sent and/or received by systems conforming to this implementation guide.

RTPBC Request Message Definition | Request for patient cost and coverage information for a prescribed medication
RTPBC Response Message Definition | Response to a request for patient cost and coverage information for a prescribed medication

### Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

RTPBC Coverage | This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process
RTPBC Medication Request | 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.
RTPBC Medication Request - Non-PHI | 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.
RTPBC Patient | 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).
RTPBC Patient - Non-PHI | 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.
RTPBC Pharmacy Organization | This profile builds on the US Core Organization to represent a pharmacy as used in the real-time pharmacy benefit check (RTPBC) process.
RTPBC Request Bundle | This profile constrains a Bundle resource for use as the request in a Real-time Pharmacy Benefit Check (RTPBC) process
RTPBC Request Bundle - Non-PHI | 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.
RTPBC Request MessageHeader | This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) request bundle
RTPBC Request Using Claim | This profile constrains the Claim resource so that it can serve as the RTPBC Request in the consumer real-time pharmacy benefit check process
RTPBC Request Using Claim - Non-PHI | 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.
RTPBC Response Bundle | This profile constrains a Bundle resource for use as the response in a Real-time Pharmacy Benefit Check (RTPBC) process
RTPBC Response MessageHeader | This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) response bundle
RTPBC Response Using ClaimResponse | 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

### Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

RTPBC benefitRestriction Extension | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
RTPBC formularyStatus Extension | This extension conveys the formulary status of a prescription product.
RTPBC isAlternative Extension | 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.
RTPBC nextAvailableFillDate Extension | 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.
RTPBC preferenceLevel Extension | This extension conveys the preference level of a prescription product.

### Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

RTPBC Benefit Restriction Value Set | 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.
RTPBC Billing Unit Value Set | This value set contains the quantity unit of measure to be used when requesting predetermination of benefits for prescription-related products
RTPBC Country Code Value Set | 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).
RTPBC Error Code Value Set | 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.
RTPBC Event Type Value Set | This value set contains event types used in RTPBC message headers.
RTPBC Formulary Status Value Set | This value set contains formulary statuses that may apply to a prescription product evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.
RTPBC Patient Pay Type Value Set | This value set contains components of a patient's responsibility for a prescription product's cost.
RTPBC Pharmacy Type Value Set | This value set contains pharmacy type categories defined in the NCPDP Pharmacy Type (955-HR) code system.
RTPBC Prescribable Product Code Value Set | 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).
RTPBC Two Letter State and Province Code Value Set | This value set contains two letter USPS state codes and Canada Post province codes.

### Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

RTPBC Benefit Restriction Code System | 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.
RTPBC Event Type Code System | This code system defines event types used in RTPBC message headers
RTPBC Formulary Status Code System | This code system defines formulary statuses that may apply to a prescription product evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.
RTPBC Patient Pay Type Code System | This code system defines components of a patient's responsibility for a prescription product's cost.

### Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

rtpbc-bundle-request-03 | An example RTPBC Request
rtpbc-bundle-request-non-phi-1 | An example non-PHI RTPBC Request
rtpbc-bundle-request-non-phi-2 | An example non-PHI RTPBC Request that omits the Patient resource
rtpbc-bundle-request-price-source | An example RTPBC request bundle
rtpbc-bundle-response-03 | An example RTPBC response bundle produced by the patient's insurer
rtpbc-bundle-response-price-source | An example RTPBC response bundle produced by cash pricing source
rtpbc-claim-03 | An example of the primary RTPBC request resource (Claim)
rtpbc-claim-non-phi-1 | An example of the non-PHI RTPBC request resource (Claim)
rtpbc-claim-non-phi-2 | An example of the non-PHI RTPBC request resource (Claim) that doesn't reference a Patient resource
rtpbc-claim-response-03 | An example RTPBC response indicating PA is required and providing patient out-of-pocket costs
rtpbc-claim-response-03-price-source | An example response from a cash pricing source
rtpbc-claim-response-not-covered | This is an example of response stating that the requested drug is not covered
rtpbc-coverage-01 | An example RTPBC Coverage
rtpbc-medicationrequest-03 | An example RTPBC MedicationRequest
rtpbc-medicationrequest-non-phi-1 | An example non-PHI RTPBC MedicationRequest
rtpbc-medicationrequest-non-phi-2 | An example non-PHI RTPBC MedicationRequest
rtpbc-organization-03 | An example RTPBC pharmacy (Organization), representing a retail pharmacy
rtpbc-organization-03m | An example RTPBC pharmacy (FHIR Organization) representing a mail order pharmacy
rtpbc-organization-03ps | An example retail pharmacy identified using an NCPDP Provider ID
rtpbc-patient-03 | An example RTPBC patient
rtpbc-patient-03ps | An example RTPBC patient with minimal content
rtpbc-patient-non-phi-1 | An example non-PHI RTPBC patient
rtpbc-practitioner-03 | An example, minimally-populated US Core Practitioner included in RTPBC examples