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

## Information Content and Fhir Resources

Page standards status: Informative

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> The STU2 version of the Consumer RTPBC guide introduces a non-PHI request for submission to data services that do not need patient-identifiable infomration to provide a response,

The real-time pharmacy benefit check (RTPBC) process involves a request from a consumer application used by a patient to either (a) the party that manages the pharmacy benefit portion of the patient's health insurance or (b) a party that serves as a source for typical and discount medication pricing information.

### Content when submitting to the patient's insurer

#### Request content

The patient application submits a request containing…

- basic patient identifying information
- payer and coverage identifiers
- information from the prescription for which coverage and cost is desired
- the patient's preferred pharmacy

Example: RTPBC request bundle

#### Response content

The responder…

- locates the patient's record and coverage details
- determines the patient's out of pocket cost for the requested pharmacy and potentially other pharmacy options
- determines if alternative medications are available and identifies coverage and cost for those
- returns the gathered information to requester

Example: RTPBC response bundle

### Content when requesting non-patient-specific info such as cash pricing

This section was modified to use a request format that contains no patient-identifiable information. Modifications are italicized.

#### Request content

The patient application submits a request containing…

- non-patient-identifiable information from the prescription: medication and quantity
- the patient's preferred pharmacy or location (ZIP Code) of the pharmacy
- non-patient-identifiable coverage information: insurance type

Example: Non-PHI RTPBC request

#### Response content

The responder…

- determines:
  - pricing for the requested pharmacy and potentially other nearby pharmacies, including discounts associated with coupons or memberships * or other medication-related information
- returns the gathered information to requester

Example: ​RTPBC response from a pricing source

### Resources used in the exchange

The consumer RTPBC request and response are accomplished using FHIR Claim and ClaimResponse resources in a "predetermination" (what-if) mode. Other FHIR® resources support the exchange by fleshing out patient, prescription, pharmacy and coverage information needed to determine accurate cost and coverage. An OperationOutcome communicates exception situations where a ClaimResponse cannot be returned.

Claim - Represents the RTPBC request. Uses the predetermination Claim.use mode

ClaimResponse - Represents the RTPBC response

Patient - Conveys the patient information needed for the exchange

Coverage - Conveys the patient's pharmacy benefit coverage IDs

MedicationRequest - Conveys the needed prescription information (a subset of what is present in a full prescription)

Organization (Pharmacy) - Conveys pharmacy information needed for the exchange (based on the US Core Organization profile)

Practitioner - Prescriber information is conveyed using the US Core Practitioner profile.

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