This CapabilityStatement describes the expected capabilities of a server that is capable of responding to a Real-time Pharmacy Benefit Check (RTPBC) request transacted with the $process-message operation.

This CapabilityStatement describes the expected capabilities of a server that is capable of responding to a Real-time Pharmacy Benefit Check (RTPBC) request transacted with the $process-message operation.

Request for patient cost and coverage information for a prescribed medication

Response to a request for patient cost and coverage information for a prescribed medication

This profile constrains the Claim resource so that it can serve as the request in the consumer Real-time Pharmacy Benefit Check (RTPBC) process.

This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process. It uses the ClaimResponse’s “predetermination” processing mode

This profile constrains the Patient resource for carrying the limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process. In RTPBC, the sole purpose of patient information is to enable the responding payer/PBM to locate the patient’s insurance information. From there, pricing and coverage information is determined based on the patient’s member and coverage information maintained by the payer.

This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process

This profile constrains the MedicationRequest resource to convey a subset of prescription information required in the consumer real-time pharmacy benefit check (RTPBC) process. The content specifies the prescribed product and quantity, and references the prescribing practitioner and the patients’ preferred pharmacy

This profile represents a pharmacy as used in the real-time pharmacy benefit check (RTPBC) process.

This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) request bundle

This profile constrains a MessageHeader resource for use in a Real-time Pharmacy Benefit Check (RTPBC) response bundle

This profile constrains a Bundle resource for use as the request in a Real-time Pharmacy Benefit Check (RTPBC) process

This profile constrains a Bundle resource for use as the response in a Real-time Pharmacy Benefit Check (RTPBC) process

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This value set includes codes used to specify prescribed medications in the US: RxNorm codes that specify drug name, strength and dose form (SBD, SCD, BPCK and GPCK term types) and NDC-11 codes (which represent specific packaged products).

This value set contains the quantity unit of measure to be used when requesting predetermination of benefits for prescription-related products

This value set contains the error codes to be used by real-time pharmacy benefit check servers when encountering a data or business condition that prevents processing from completing. Values are defined in the NCPDP-maintained Reject Code (511-FB) code set.

This value set contains event types used in RTPBC message headers.

This value set contains a subset of two-letter ISO 3166-1-2 country codes for the countries in which this profile is intended to be used (US and CA).

This value set contains 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.

This value set contains components of a patient’s responsibility for a prescription product’s cost.

This value set contains pharmacy type categories defined in the NCPDP Pharmacy Type (955-HR) code system.

This value set contains two letter USPS state codes and Canada Post province codes.

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.

This code system defines event types used in RTPBC message headers

This code system defines components of a patient’s responsibility for a prescription product’s cost.

Canada Post province codes

The NCPDP Pharmacy Type (955-HR) code set defines a set of pharmacy type categories.

The NCPDP Pharmacy Type (955-HR) code set defines a set of pharmacy type categories.

The NCPDP Reject Code (511-FB) code set contains exception definitions for use when transaction processing cannot be completed.

Example of a consumer RTPBC Claim resource.

Example of a consumer RTPBC Claim resource submitted to a pricing source.

Example of a consumer RTPBC ClaimResponse resource.

Example of a consumer RTPBC ClaimResponse resource when the requested drug is not covered.

Example of a consumer RTPBC ClaimResponse resource from a pricing source.

Example of a consumer RTPBC Patient resource.

Example of a consumer RTPBC Coverage resource.

Example of a consumer RTPBC MedicationRequest resource.

Example of a consumer RTPBC pharmacy Organization resource.

Example of a consumer RTPBC pharmacy Organization resource.

Example of a consumer RTPBC request MessageHeader resource.

Example of a consumer RTPBC response MessageHeader resource.

Example of a consumer RTPBC request Bundle resource.

Example of a consumer RTPBC request Bundle resource submitted to a pricing source.

Example of a consumer RTPBC response Bundle resource.

Example of a consumer RTPBC response Bundle resource returned by a pricing source.

Example of a US Core Practitioner resource representing a prescriber in the RTPBC exchange.