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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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:CodeSystem ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "rtpbc-benefit-restriction-temporary"] ; #
      fhir:language [ fhir:v "en"] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm>     ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 2     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "phx"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "trial-use" ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom>         ] ;
    fhir:value [
    a fhir:Canonical ;
    fhir:v "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc>         ]       ] )     ]
      ] ) ; #
      fhir:url [
    fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary>
      ] ; #
      fhir:version [ fhir:v "2.0.0-ballot"] ; #
      fhir:name [ fhir:v "RtpbcBenefitRestrictionCodeSystem"] ; #
      fhir:title [ fhir:v "RTPBC Benefit Restriction Code System (Temporary)"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:experimental [ fhir:v false] ; #
      fhir:date [ fhir:v "2026-03-01T00:00:00-05:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Pharmacy"] ; #
      fhir:contact ( [
    fhir:name [ fhir:v "HL7 International / Pharmacy" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/medication" ]     ] )
      ] [
    fhir:name [ fhir:v "Frank McKinney" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "email" ] ;
    fhir:value [ fhir:v "fm@frankmckinney.com" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "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)"] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ;
    fhir:l <urn:iso:std:iso:3166>       ] ;
    fhir:code [ fhir:v "US" ] ;
    fhir:display [ fhir:v "United States of America" ]     ] )
      ] ) ; #
      fhir:caseSensitive [ fhir:v false] ; #
      fhir:content [ fhir:v "complete"] ; #
      fhir:count [ fhir:v "11"^^xsd:nonNegativeInteger] ; #
      fhir:concept ( [
    fhir:code [ fhir:v "covered" ] ;
    fhir:display [ fhir:v "Covered" ] ;
    fhir:definition [ fhir:v "Covered" ]
      ] [
    fhir:code [ fhir:v "prior-auth" ] ;
    fhir:display [ fhir:v "Prior authorization required" ] ;
    fhir:definition [ fhir:v "Covered with restriction: Prior authorization required" ]
      ] [
    fhir:code [ fhir:v "step-therapy" ] ;
    fhir:display [ fhir:v "Step therapy applies" ] ;
    fhir:definition [ fhir:v "Covered with restriction: Step therapy applies" ]
      ] [
    fhir:code [ fhir:v "quantity-limit" ] ;
    fhir:display [ fhir:v "Quantity limit applies" ] ;
    fhir:definition [ fhir:v "Covered with restriction: Quantity limit applies" ]
      ] [
    fhir:code [ fhir:v "pharmacy-restriction" ] ;
    fhir:display [ fhir:v "Pharmacy restriction applies" ] ;
    fhir:definition [ fhir:v "Covered with restriction: Pharmacy restriction applies" ]
      ] [
    fhir:code [ fhir:v "other-restriction" ] ;
    fhir:display [ fhir:v "Other restriction applies" ] ;
    fhir:definition [ fhir:v "Covered with restriction: Other restriction applies" ]
      ] [
    fhir:code [ fhir:v "not-covered" ] ;
    fhir:display [ fhir:v "Not covered" ] ;
    fhir:definition [ fhir:v "Not covered" ]
      ] [
    fhir:code [ fhir:v "additional-fills-not-covered" ] ;
    fhir:display [ fhir:v "Additional fills not covered" ] ;
    fhir:definition [ fhir:v "Additional fills are not covered" ]
      ] [
    fhir:code [ fhir:v "fill-too-soon" ] ;
    fhir:display [ fhir:v "Fill too soon" ] ;
    fhir:definition [ fhir:v "Fill too soon" ]
      ] [
    fhir:code [ fhir:v "days-supply-limitation" ] ;
    fhir:display [ fhir:v "Days supply limitation for product/service" ] ;
    fhir:definition [ fhir:v "Days supply limitation for the product/service" ]
      ] [
    fhir:code [ fhir:v "route-not-covered" ] ;
    fhir:display [ fhir:v "Route of administration not covered" ] ;
    fhir:definition [ fhir:v "Route of administration is not covered" ]
      ] ) . #