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CARIN Real-time Pharmacy Benefit Check Workgroup Call 082319

Welcome, roll call, and anti-trust reminder.

The group discussed the goals of Connectathon:

  1. Focused on Use Case 1 (cash price and formulary price).
  2. The current IG and mapping process have been informed by HL7 work groups and are focused on claim and claim response. This was based on the back-end adjudication process that most PBMs use.
  3. Some in the RTPBC group wanted eligibility and eligibility response resources (would need expansion of the current resource but that was desired). On the call, it was noted that this would be closer to the medical-benefit check.
  4. What is the group’s desired approach to the Connectathon?
    1. IG was the goal but unlikely
    2. Now focused on approach of data exchange between app developer and PBM/Payer and Cash/Discount Price Vendor (claim/claim.resource or another transaction)
  5. What documentation is needed?
    1. PBM request and response from the claim resource
    2. Cash/discount vendor open questions:
      1. Two separate API calls or one? Some discount/cash vendors can digest the same calls that PBMs do but don’t utilize all fields. Unclear if this is universal. GROUP DECISION: Test One API request; cash/discount vendor can ignore fields not needed
      2. Could the mobile app send the same request but receive different responses? GROUP DECISION: YES
    3. What is the timing for the API responses (expectation for cash and PBM is under 1 second). Calls need to be time-bound and disclaimers about the timing of the discounted price and use of coupons/discount cards/benefits.
    4. Small group will review options for transaction.
    5. Can we bifurcate the ID component from the pricing call?
      1. How frequently do plans communicate with PBMs about plan information?
      2. Can we pull ID from the testing? GROUP DECISION: Yes. For September, ID of PBM/Healthplan and Patient will be removed
    6. Next Call: Off schedule call scheduled for Friday, August 30th at 11 ET.


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