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