Consumer Real-Time Pharmacy Benefit Check
1.0.0 - STU1

This page is part of the Consumer Real-time Pharmacy Benefit Check (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example RTPBC Response - not covered

Format(s):

RTPBC ClaimResponse - requested drug is not covered

In this example:

  • the requested medication is not covered by the patient's plan. The Benefit Restriction contains a value of "not-covered" and the adjucation shows an eligible amount of zero dollars.
  • the addItem contains an alternative drug that is covered, but with a requirement for prior authorziation and a quantity limit. Details of the quantity limit are conveyed in the processNote element.
claimresponse

Narrative view

Generated Narrative

id: rtpbc-claim-response-not-covered

meta:

identifier: id: rtpbc-03-response-c-r

status: active

type: Pharmacy

use: predetermination

patient: Generated Summary: id: rtpbc-patient-03; Patient internal identifier: 30455; Jane Doe ; gender: female; birthDate: 1975-12-05

created: Nov 1, 2019 4:20:59 PM

insurer:

request:

outcome: complete

disposition: Processed successfully

item

itemSequence: 1

Adjudications

-CategoryAmount
*Eligible amount

addItem

itemSequence: 1

provider: Generated Summary: id: rtpbc-organization-03m; id: 0999029; active; Mail Order; name: My Mail Service Pharmacy; ph: 5551234567

productOrService: Zepatier 50 MG / 100 MG Oral Tablet

quantity: 28 {Each}

noteNumber: 1

Adjudications

-CategoryAmount
*Copay
*Per prescription coinsurance
*Total patient responsibility

ProcessNotes

-NumberText
*1Quantity limit: 28 tablets per month