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-03

Page standards status: Informative

### Example RTPBC ClaimResponse (the "RTPBC response")

In this example:

- the requested medication is Prozac 10mg capsule, 60 capsules, and the requested pharmacy is Hometown Drug. Adjudication is 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 referenced 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 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: 2025-12-11 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: prior-auth (Prior authorization required)

> RTPBC formularyStatus Extension: RTPBC Formulary Status Code System: O (On Formulary)

> RTPBC preferenceLevel Extension: 2

> RTPBC nextAvailableFillDate Extension: 2025-12-20

> itemSequence: 1

> > adjudication

> > category: Copay

> > ### Amounts

> > - | Value | Currency
> > * | 40 | United States dollar

> > adjudication

> > category: Per prescription coinsurance

> > ### Amounts

> > - | Value | Currency
> > * | 30 | United States dollar

> > adjudication

> > category: Total patient responsibility

> > ### Amounts

> > - | Value | Currency
> > * | 70 | United States dollar

> addItem

> RTPBC isAlternative Extension: true

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

> RTPBC formularyStatus Extension: RTPBC Formulary Status Code System: P (On Formulary/Preferred)

> RTPBC preferenceLevel Extension: 1

> itemSequence: 1

> provider: Organization My Mail Service Pharmacy

> productOrService: fluoxetine 10 MG Oral Capsule [Prozac]

> quantity: 180 {Each}

> > adjudication

> > category: Remaining deductible

> > ### Amounts

> > - | Value | Currency
> > * | 305 | United States dollar

> > adjudication

> > category: Per prescription coinsurance

> > ### Amounts

> > - | Value | Currency
> > * | 30 | United States dollar

> > adjudication

> > category: Total patient responsibility

> > ### Amounts

> > - | Value | Currency
> > * | 70 | United States dollar