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CARIN Real-time Pharmacy Benefit Check (RTPBC)[edit | edit source]

Owning Workgroup[edit | edit source]

Pharmacy

Committee Approval Date:[edit | edit source]

Requested November 2019

Publishing Lead[edit | edit source]

Frank McKinney (fm@frankmckinney.com)

Contributing or Reviewing Work Groups[edit | edit source]

Financial Management

FHIR Development Project Insight ID[edit | edit source]

1543

Scope of coverage[edit | edit source]

This is a guide for implementing the consumer-focused real-time pharmacy benefit check using FHIR R4.

The guide is for use in the United States only.

The process is limited to medications that are covered under the pharmacy benefit portion of the patient’s health insurance, which typically excludes medications administered during hospital care or as part of medical procedures. It is further limited to commercially available medication products that are not compounded at the pharmacy.

Content location[edit | edit source]

https://github.com/HL7/carin-rtpbc

Proposed IG realm and code[edit | edit source]

us/carin-rtpbc

Maintenance Plan[edit | edit source]

The CARIN Alliance is committed to the maintenance of the content.

The Pharmacy and Financial Management Workgroups are engaged and will continue to provide guidance and review through completion of the guide.

Short Description[edit | edit source]

CARIN Real-time Pharmacy Benefit Check (RTPBC) FHIR Implementation Guide

Long Description[edit | edit source]

Using Real-time Pharmacy Benefit Check (RTPBC), a patient can learn how their medications will be covered at the pharmacy, including out of pocket costs and coverage restrictions or requirements that might apply.

The communication flow consists of...

  • a request submitted by a consumer application that contains information about the patient, the prescription and their insurance coverage
  • a response from the patient's insurer that contains cost and coverage information for the requested product, alternative products, and different pharmacy options.

This IG defines FHIR profiles for resources representing...

  • the set of information provided in the RTPBC request that enables the insurer to locate the patient's membership details and determine coverage for the requested product. This includes profiles of Claim, Patient, Practitioner, Organization and MedicationRequest resources
  • the pricing and coverage information returned in the RTPBC response, using a profile of the ClaimResponse.

In addition, the guide identifies terminology to identify the referenced entities and aspects of insurance coverage.

Involved parties[edit | edit source]

The RTPBC IG is being authored by the CARIN Alliance in collaboration with the National Council for Prescription Drug Programs (NCPDP), HL7 Pharmacy and Financial Management workgroups.

Expected implementations[edit | edit source]

CARIN Alliance members including health plans, pharmacy benefit managers and consumer application vendors.

Content sources[edit | edit source]

The CARIN consumer RTPBC process is an adaptation of the NCPDP provider-focused Real-time Pharmacy Benefit Check transactions. The effort consulting NCPDP in addition the HL7 Pharmacy and Financial Management workgroups and the CARIN Alliance participants while developing this guide.

Example Scenarios[edit | edit source]

Retrieve patient-specific cost and coverage information for a medication product

IG Relationships[edit | edit source]

The IG is based on core FHIR R4.

Timelines[edit | edit source]

STU ballot in the January 2020 cycle


FMG Notes

FMG approved 11/6/2019