RTPBC ClaimResponse - requested drug is not covered

In this example:

• the requested medication is not covered by the patient's plan. The Benefit Restriction contains a value of "not-covered" and the adjucation shows an eligible amount of zero dollars.
• the addItem contains an alternative drug that is covered, but with a requirement for prior authorziation and a quantity limit. Details of the quantity limit are conveyed in the processNote element.

identifier: rtpbc-03-response-c-r

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: Processing Complete

disposition: Processed successfully

item

RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System not-covered: Not covered

itemSequence: 1

adjudication

category: Eligible amount

Amounts

-	Value	Currency
*	0	United States dollar

addItem

RTPBC isAlternative Extension: true

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

RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System quantity-limit: Quantity limit applies

itemSequence: 1

provider: Organization My Mail Service Pharmacy

productOrService: Zepatier 50 MG / 100 MG Oral Tablet

quantity: 28 {Each}

noteNumber: 1

adjudication

category: Copay

Amounts

-	Value	Currency
*	405	United States dollar

adjudication

category: Per prescription coinsurance

Amounts

-	Value	Currency
*	469	United States dollar

adjudication

category: Total patient responsibility

Amounts

-	Value	Currency
*	874	United States dollar

ProcessNotes