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1a. Project Name

PSS for CARIN Consumer-facing Real-time Pharmacy Benefit Check

1b. Project ID

1543

1c. Is Your Project an Investigative Project (aka PSS-Lite)?

No

1d. Is your Project Artifact being Reaffirmed or proceeding to Normative directly after being either Informative or STU?

No

1e. Today's Date

1f. Name of standard being reaffirmed

1g. Project Artifact Information

1h. ISO/IEC Standard to Adopt

1i. Does the standard include excerpted text from one or more ISO, IEC or ISO/IEC standards, but is not an identical or modified adoption?

1j. Unit of Measure

2a. Primary/Sponsor WG

Payer/Provider Information Exchange

2b. Co-Sponsor WG

Health Care Devices

2c. Co-Sponsor Level of Involvement

Request formal content review prior to ballot

2c. Co-Sponsor Update Periods

Periodic updates between meetings during interim calls and at WGMs

2d. Project Facilitator

Pooja Babbrah, Jean Duteau

2e. Other Interested Parties (and roles)

2f. Modeling Facilitator

2g. Publishing Facilitator

Pooja Babrah, Paul Knapp

2h. Vocabulary Facilitator

Tim McNeil

2i. Domain Expert Representative

2j. Business Requirements Analyst

2k. Conformance Facilitator

Pooja Babbrah

2l. Other Facilitators

2m. Implementers

Humana, Cambia

3a. Project Scope

Develop a FHIR R4 based implementation guide for an API similar to the NCPDP Real-Time Pharmacy Benefit Check B2B standard that will allow consumers access to the same information as their providers including information related to their cash price. This information includes formulary and benefit information, OOP costs, therapeutic alternatives, and cash price through an API that would be accessible by the consumer through a third-party application.

Attachments

3b. Project Need

The final Medicare Part D rule for 2020 (https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-and-part-d-drug-pricing-final-rule-cms-4180-f#_Prohibition_Against_Gag) requires all Medicare Part D plans to send members information on lower cost therapeutic alternatives and requires the implementation of a real-time pharmacy benefit tool by 2021.

3c. Security Risk

No

3d. External Drivers

Final Medicare Part D rule for 2020

3e. Objectives/Deliverables and Target Dates

A FHIR R4 Implementation Guide
The desired ballot is January 2020.
Rough timeline
8/2019 - Draft implementation guide published
9/2019 - Connectathon
10/2019 - Development and Connectathon outcomes documented and presented to Pharmacy Work Group
11/2019 - Ballot material approved by Pharmacy Work Group
1/2020 - Ballot

3f. Common Names / Keywords / Aliases:

CARIN, RTPBC, RTBT, RTBC, real-time pharmacy benefit check

3g. Lineage

3h. Project Dependencies

None

3i. HL7-Managed Project Document Repository URL:

https://confluence.hl7.org/display/CAR/RTPBC+Workgroup

3j. Backwards Compatibility

No

3k. Additional Backwards Compatibility Information (if applicable)

3l. Using Current V3 Data Types?

N/A

3l. Reason for not using current V3 data types?

3m. External Vocabularies

Yes

3n. List of Vocabularies

NCPDP
Additional vocabularies to be added here

3o. Earliest prior release and/or version to which the compatibility applies

None

4a. Products

FHIR Extensions, FHIR Profiles, FHIR Resources

4b. For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to?

R4

4c. FHIR Profiles Version

R4

4d. Please define your New Product Definition

4d. Please define your New Product Family

5a. Project Intent

Implementation Guide (IG) will be created/modified

5a. White Paper Type

5a. Is the project adopting/endorsing an externally developed IG?

No

5a. Externally developed IG is to be (select one)

5a. Specify external organization

CARIN Alliance

5a. Revising Current Standard Info

5b. Project Ballot Type

STU to Normative

5c. Additional Ballot Info

January 2020 is the desired ballot date.

5d. Joint Copyright

Yes

5e. I understand I must submit a Joint Copyright Letter of Agreement to the TSC in order for the PSS to receive TSC approval.

no

6a. External Project Collaboration

CARIN Alliance

6b. Content Already Developed

0%

6c. Content externally developed?

No

6d. List Developers of Externally Developed Content

6e. Is this a hosted (externally funded) project?

Yes

6f. Stakeholders

Regulatory Agency, Standards Development Organizations (SDOs), Payors, Other

6f. Other Stakeholders

NCPDP, Consumer

6g. Vendors

Pharmaceutical, Health Care IT

6g. Other Vendors

6h. Providers

Healthcare Institutions (hospitals, long term care, home care, mental health)

6h. Other Providers

6i. Realm

U.S. Realm Specific

7d. US Realm Approval Date

Jun 18, 2019

7a. Management Group(s) to Review PSS

FHIR

7b. Sponsoring WG Approval Date

Jun 24, 2019

7c. Co-Sponsor Approval Date

Jul 02, 2019

7c. Co-Sponsor 2 Approval Date

7c. Co-Sponsor 3 Approval Date

7c. Co-Sponsor 4 Approval Date

7c. Co-Sponsor 5 Approval Date

7c. Co-Sponsor 6 Approval Date

7c. Co-Sponsor 7 Approval Date

7c. Co-Sponsor 8 Approval Date

7c. Co-Sponsor 9 Approval Date

7c. Co-Sponsor 10 Approval Date

7e. CDA MG Approval Date

7f. FMG Approval Date

May 29, 2019

7g. V2 MG Approval Date

7h. Architecture Review Board Approval Date

7i. Steering Division Approval Date

Jul 24, 2019

7j. TSC Approval Date

Sep 09, 2019


























10 Comments

  1. Ryan Howells Needs percentage of content externally developed, who developed the content, and cosponsor approval date. 

  2. Anne Wizauer Complete. Cosponsor approval date forthcoming.

  3. It's not clear to me that NCPDP is directly involved in this project even though the scope basically says this work will be similar to an NCPDP API. HL7 has an SOU with NCPDP that covers joint work and joint copyrights.

    1. They are involved and very supportive. 

  4. Is FM the right home for this project? How does it relate to CDS Hooks which enables real-time checks?

  5. Pharmacy WG has indicated that they would like to be the sponsor of this project given it seems to overlap with the daVinci Formulary Implementation Guide that Pharmacy owns.

  6. Have you presented to Clinical Decision Support Work Group?

  7. Ryan Howells Pooja Babbrah In preparing this for TSC e-vote, I noticed that it is still missing the link to the HL7-managed project document repository in section 3.i. One you've got that entered, I will send it for their review.

  8. Anne Wizauer  - Section 3.i has been updated.  Please let me know if you need anything else.