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

## CodeSystem: RTPBC Benefit Restriction Code System (Temporary)

Official URL: http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Trial-use Active as of 2026-03-01 | Maturity Level: 2 | Computable Name: RtpbcBenefitRestrictionCodeSystem

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)

This Code system is referenced in the definition of the following value sets:

- RtbpcBenefitRestrictionValueSet

This case-insensitive code system `http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary` defines the following codes:

Code | Display | Definition
covered | Covered | Covered
prior-auth | Prior authorization required | Covered with restriction: Prior authorization required
step-therapy | Step therapy applies | Covered with restriction: Step therapy applies
quantity-limit | Quantity limit applies | Covered with restriction: Quantity limit applies
pharmacy-restriction | Pharmacy restriction applies | Covered with restriction: Pharmacy restriction applies
other-restriction | Other restriction applies | Covered with restriction: Other restriction applies
not-covered | Not covered | Not covered
additional-fills-not-covered | Additional fills not covered | Additional fills are not covered
fill-too-soon | Fill too soon | Fill too soon
days-supply-limitation | Days supply limitation for product/service | Days supply limitation for the product/service
route-not-covered | Route of administration not covered | Route of administration is not covered

Description of the above table(s).