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 Bundle: rtpbc-bundle-response-03

### Example RTPBC response scenario using FHIR messaging

In this example:

- the client is a patient application
- the server is the patient's insurer (specifically, the party that manages the patient's pharmacy benefit)
- the response is returned as a Bundle containing a ClaimResponse and supporting resources, in response to a $process-message operation

Content:

- the requested medication is Prozac 10mg capsule, 60 capsules, and the requested pharmacy is Hometown Drug. Adjudication returned in the ClaimResponse.item composite
- the .item contains patient costs for the requested drug and pharmacy combination
- the .addItem composite holds an alternative fulfillment (the requested drug at a different pharmacy). Adjudication is returned in the ClaimResponse.addItem composite
- a pharmacy Organization resource describes the alternative pharmacy option identified by the processor
- benefit restriction information (e.g., Covered, Covered but requiring PA) is returned in the .benefitRestriction extensions in the .item and .addItem composites

Language: en

Profile: RTPBC Response Bundle

Bundle rtpbc-bundle-response-03 of type message

Entry 1 - fullUrl = http://example.org/my-app/MessageHeader/rtpbc-messageheader-response-03wh

Resource MessageHeader:

> Language: en

> Profile: RTPBC Response MessageHeader

> event: RTPBC Event Type Code System: rtpbc-response (RTPBC Response)

> ### Sources

> - | Name
> * | PharmacyBenefitsCompany

> ### Responses

> - | Identifier | Code
> * | rtpbc-messageheader-request-03 | OK

> focus: ClaimResponse: identifier = rtpbc-03-response; status = active; type = Pharmacy; use = predetermination; created = 2019-11-01 11:20:59-0500; outcome = complete; disposition = Processed successfully

> definition: RTPBC Response Message Definition

Entry 2 - fullUrl = http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh

Resource ClaimResponse:

> Language: en

> Profile: RTPBC Response Using ClaimResponse

> identifier: rtpbc-03-response

> 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: complete

> disposition: Processed successfully

> > item

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

> > itemSequence: 1

> > > adjudication

> > > category: Copay

> > > ### Amounts

> > > - | Value | Currency
> > > * | 40 | USD

> > > adjudication

> > > category: Per prescription coinsurance

> > > ### Amounts

> > > - | Value | Currency
> > > * | 30 | USD

> > > adjudication

> > > category: Total patient responsibility

> > > ### Amounts

> > > - | Value | Currency
> > > * | 70 | USD

> > addItem

> > RTPBC isAlternative Extension: true

> > RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System: covered (Covered)

> > itemSequence: 1

> > provider: Organization My Mail Service Pharmacy

> > productOrService: fluoxetine 10 MG Oral Capsule [Prozac]

> > quantity: 180 {Each}

> > > adjudication

> > > category: Copay

> > > ### Amounts

> > > - | Value | Currency
> > > * | 20 | USD

> > > adjudication

> > > category: Per prescription coinsurance

> > > ### Amounts

> > > - | Value | Currency
> > > * | 30 | USD

> > > adjudication

> > > category: Total patient responsibility

> > > ### Amounts

> > > - | Value | Currency
> > > * | 50 | USD

Entry 3 - fullUrl = http://example.org/my-app/Patient/rtpbc-patient-03

Resource Patient:

> Language: en

> Profile: RTPBC Patient

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

> Contact Detail | 100 Oak Court Madison WI 53510 US

Entry 4 - fullUrl = http://example.org/my-app/Organization/rtpbc-organization-03m

Resource Organization:

> Language: en

> Profile: RTPBC Pharmacy Organization

> identifier: NCPDP Provider Identification Number/0999029

> active: true

> type: Mail Order

> name: My Mail Service Pharmacy

> ### Contacts

> - | Telecom | Address
> * | ph: 5551234567 | 10001 Oakland Road Milwaukee WI 54444 US