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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    {
      "resourceType" : "CodeSystem",
      "id" : "rtpbc-benefit-restriction-temporary",
      "language" : "en",
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
          "valueInteger" : 2
        },
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "phx"
        },
        {
          "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-temporary",
      "version" : "2.0.0-ballot",
      "name" : "RtpbcBenefitRestrictionCodeSystem",
      "title" : "RTPBC Benefit Restriction Code System (Temporary)",
      "status" : "active",
      "experimental" : false,
      "date" : "2026-03-01T00:00:00-05:00",
      "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. (A THO URL has been requested for this code system)",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "US",
              "display" : "United States of America"
            }
          ]
        }
      ],
      "caseSensitive" : false,
      "content" : "complete",
      "count" : 11,
      "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"
        },
        {
          "code" : "additional-fills-not-covered",
          "display" : "Additional fills not covered",
          "definition" : "Additional fills are not covered"
        },
        {
          "code" : "fill-too-soon",
          "display" : "Fill too soon",
          "definition" : "Fill too soon"
        },
        {
          "code" : "days-supply-limitation",
          "display" : "Days supply limitation for product/service",
          "definition" : "Days supply limitation for the product/service"
        },
        {
          "code" : "route-not-covered",
          "display" : "Route of administration not covered",
          "definition" : "Route of administration is not covered"
        }
      ]
    }