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. For a full list of available versions, see the Directory of published versions

Information Content and FHIR Resources

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The real-time pharmacy benefit check (RTPBC) process involves a request from a consumer application used by a patient to either (a) the party that manages the pharmacy benefit portion of the patient’s health insurance or (b) a party that serves as a source for typical and discount medication pricing information.

Content when submitting to the patient’s insurer

Request content

The patient application submits a request containing…

• basic patient identifying information
• payer and coverage identifiers
• information from the prescription for which coverage and cost is desired
• the patient’s preferred pharmacy

Example: Bundled RTPBC request

Response content

The responder…

• locates the patient’s record and coverage details
• determines the patient’s out of pocket cost for the requested pharmacy and potentially other pharmacy options
• determines if alternative medications are available and identifies coverage and cost for those
• returns the gathered information to requester

Example: Bundled RTPBC response from payer/PBM

Content when submitting to a medication pricing source

Request content

The patient application submits a request containing…

• basic patient identifying information
• identification of the pricing source
• information from the prescription for which pricing is desired
• the patient’s location and preferred pharmacy

Response content

The responder…

• determines pricing for the requested pharmacy and potentially other nearby pharmacies, including discounts associated with coupons or memberships
• returns the gathered information to requester

Resources used in the exchange

The consumer RTPBC request and response are accomplished using FHIR Claim and ClaimResponse resources in a “predetermination” (what-if) mode. Other FHIR® resources support the exchange by fleshing out patient, prescription, pharmacy and coverage information needed to determine accurate cost and coverage. An OperationOutcome communicates exception situations where a ClaimResponse cannot be returned.

Claim - Represents the RTPBC request. Uses the predetermination Claim.use mode

ClaimResponse - Represents the RTPBC response

Patient - Conveys the patient information needed for the exchange

Coverage - Conveys the patient’s pharmacy benefit coverage IDs

MedicationRequest - Conveys the needed prescription information (a subset of what is present in a full prescription)

Organization (Pharmacy) - Conveys pharmacy information needed for the exchange (based on the US Core Organization profile)

Practitioner - Prescriber information is conveyed using the US Core Practitioner profile.

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