Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build United States of America flag

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

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

-ValueCurrency
*40United States dollar

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*70United 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

-ValueCurrency
*305United States dollar

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*70United States dollar