Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0-ballot - STU 2 Ballot

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-ballot 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 Benefit Restriction Code System (Temporary)

Page standards status: Trial-use | Maturity Level: 2

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    <CodeSystem xmlns="http://hl7.org/fhir">
      <id value="rtpbc-benefit-restriction-temporary"/>
      <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-benefit-restriction-temporary</b></p><a name="rtpbc-benefit-restriction-temporary"> </a><a name="hcrtpbc-benefit-restriction-temporary"> </a><p>This case-insensitive code system <code>http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary</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-temporary-covered"> </a></td><td>Covered</td><td>Covered</td></tr><tr><td style="white-space:nowrap">prior-auth<a name="rtpbc-benefit-restriction-temporary-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-temporary-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-temporary-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-temporary-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-temporary-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-temporary-not-covered"> </a></td><td>Not covered</td><td>Not covered</td></tr><tr><td style="white-space:nowrap">additional-fills-not-covered<a name="rtpbc-benefit-restriction-temporary-additional-fills-not-covered"> </a></td><td>Additional fills not covered</td><td>Additional fills are not covered</td></tr><tr><td style="white-space:nowrap">fill-too-soon<a name="rtpbc-benefit-restriction-temporary-fill-too-soon"> </a></td><td>Fill too soon</td><td>Fill too soon</td></tr><tr><td style="white-space:nowrap">days-supply-limitation<a name="rtpbc-benefit-restriction-temporary-days-supply-limitation"> </a></td><td>Days supply limitation for product/service</td><td>Days supply limitation for the product/service</td></tr><tr><td style="white-space:nowrap">route-not-covered<a name="rtpbc-benefit-restriction-temporary-route-not-covered"> </a></td><td>Route of administration not covered</td><td>Route of administration is not covered</td></tr></table></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
        <valueInteger value="2"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="phx"/>
      </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-benefit-restriction-temporary"/>
      <version value="2.0.0-ballot"/>
      <name value="RtpbcBenefitRestrictionCodeSystem"/>
      <title value="RTPBC Benefit Restriction Code System (Temporary)"/>
      <status value="active"/>
      <experimental value="false"/>
      <date value="2026-03-01T00:00:00-05:00"/>
      <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 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. (A THO URL has been requested for this code system)"/>
      <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="11"/>
      <concept>
        <code value="covered"/>
        <display value="Covered"/>
        <definition value="Covered"/>
      </concept>
      <concept>
        <code value="prior-auth"/>
        <display value="Prior authorization required"/>
        <definition
                    value="Covered with restriction: Prior authorization required"/>
      </concept>
      <concept>
        <code value="step-therapy"/>
        <display value="Step therapy applies"/>
        <definition value="Covered with restriction: Step therapy applies"/>
      </concept>
      <concept>
        <code value="quantity-limit"/>
        <display value="Quantity limit applies"/>
        <definition value="Covered with restriction: Quantity limit applies"/>
      </concept>
      <concept>
        <code value="pharmacy-restriction"/>
        <display value="Pharmacy restriction applies"/>
        <definition
                    value="Covered with restriction: Pharmacy restriction applies"/>
      </concept>
      <concept>
        <code value="other-restriction"/>
        <display value="Other restriction applies"/>
        <definition value="Covered with restriction: Other restriction applies"/>
      </concept>
      <concept>
        <code value="not-covered"/>
        <display value="Not covered"/>
        <definition value="Not covered"/>
      </concept>
      <concept>
        <code value="additional-fills-not-covered"/>
        <display value="Additional fills not covered"/>
        <definition value="Additional fills are not covered"/>
      </concept>
      <concept>
        <code value="fill-too-soon"/>
        <display value="Fill too soon"/>
        <definition value="Fill too soon"/>
      </concept>
      <concept>
        <code value="days-supply-limitation"/>
        <display value="Days supply limitation for product/service"/>
        <definition value="Days supply limitation for the product/service"/>
      </concept>
      <concept>
        <code value="route-not-covered"/>
        <display value="Route of administration not covered"/>
        <definition value="Route of administration is not covered"/>
      </concept>
    </CodeSystem>