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

• Narrative Content
• XML
• JSON
• TTL

: RTPBC Benefit Restriction Code System - JSON Representation

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{
  "resourceType" : "CodeSystem",
  "id" : "rtpbc-benefit-restriction",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem rtpbc-benefit-restriction</b></p><a name=\"rtpbc-benefit-restriction\"> </a><a name=\"hcrtpbc-benefit-restriction\"> </a><p>This case-insensitive code system <code>http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction</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\">covered<a name=\"rtpbc-benefit-restriction-covered\"> </a></td><td>Covered</td><td>Covered</td></tr><tr><td style=\"white-space:nowrap\">prior-auth<a name=\"rtpbc-benefit-restriction-prior-auth\"> </a></td><td>Prior authorization required</td><td>Covered with restriction: Prior authorization required</td></tr><tr><td style=\"white-space:nowrap\">step-therapy<a name=\"rtpbc-benefit-restriction-step-therapy\"> </a></td><td>Step therapy applies</td><td>Covered with restriction: Step therapy applies</td></tr><tr><td style=\"white-space:nowrap\">quantity-limit<a name=\"rtpbc-benefit-restriction-quantity-limit\"> </a></td><td>Quantity limit applies</td><td>Covered with restriction: Quantity limit applies</td></tr><tr><td style=\"white-space:nowrap\">pharmacy-restriction<a name=\"rtpbc-benefit-restriction-pharmacy-restriction\"> </a></td><td>Pharmacy restriction applies</td><td>Covered with restriction: Pharmacy restriction applies</td></tr><tr><td style=\"white-space:nowrap\">other-restriction<a name=\"rtpbc-benefit-restriction-other-restriction\"> </a></td><td>Other restriction applies</td><td>Covered with restriction: Other restriction applies</td></tr><tr><td style=\"white-space:nowrap\">not-covered<a name=\"rtpbc-benefit-restriction-not-covered\"> </a></td><td>Not covered</td><td>Not covered</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "phx"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 4,
      "_valueInteger" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction",
  "version" : "2.0.0",
  "name" : "RtpbcBenefitRestrictionCodeSystem",
  "title" : "RTPBC Benefit Restriction Code System",
  "status" : "active",
  "experimental" : false,
  "date" : "2020-05-23T00:00:00-05:00",
  "publisher" : "HL7 International / Pharmacy",
  "contact" : [
    {
      "name" : "HL7 International / Pharmacy",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/medication"
        }
      ]
    },
    {
      "name" : "Frank McKinney",
      "telecom" : [
        {
          "system" : "email",
          "value" : "fm@frankmckinney.com"
        }
      ]
    }
  ],
  "description" : "This code system defines a set of benefit restrictions that may apply to a prescription product and pharmacy combination evaluated in the Real-time Pharmacy Benefit Check (RTPBC) process.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "caseSensitive" : false,
  "content" : "complete",
  "count" : 7,
  "concept" : [
    {
      "code" : "covered",
      "display" : "Covered",
      "definition" : "Covered"
    },
    {
      "code" : "prior-auth",
      "display" : "Prior authorization required",
      "definition" : "Covered with restriction: Prior authorization required"
    },
    {
      "code" : "step-therapy",
      "display" : "Step therapy applies",
      "definition" : "Covered with restriction: Step therapy applies"
    },
    {
      "code" : "quantity-limit",
      "display" : "Quantity limit applies",
      "definition" : "Covered with restriction: Quantity limit applies"
    },
    {
      "code" : "pharmacy-restriction",
      "display" : "Pharmacy restriction applies",
      "definition" : "Covered with restriction: Pharmacy restriction applies"
    },
    {
      "code" : "other-restriction",
      "display" : "Other restriction applies",
      "definition" : "Covered with restriction: Other restriction applies"
    },
    {
      "code" : "not-covered",
      "display" : "Not covered",
      "definition" : "Not covered"
    }
  ]
}