CARIN RTPBC FHIR IG Proposal

CARIN Real-time Pharmacy Benefit Check (RTPBC)

Owning Workgroup

Pharmacy

Committee Approval Date:

Project approved by Pharmacy June 24, 2019

Publishing Lead

Frank McKinney (fm@frankmckinney.com)

Contributing or Reviewing Work Groups

Financial Management

FHIR Development Project Insight ID

1543

Scope of coverage

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

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

Proposed IG realm and code

us/carin-rtpbc

Maintenance Plan

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

CARIN Real-time Pharmacy Benefit Check (RTPBC) FHIR Implementation Guide. Using RTPBC, a patient can learn how much their medication will cost and how it will be covered by their insurance, including out of pocket costs and any coverage restrictions or requirements that might apply. The RTPBC request is sent by a patient application to the patient's insurer (who responds with patient-specific cost and coverage information) and to medication pricing sources (who respond with typical and discounted pharmacy pricing).

Long Description

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

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

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

Content sources

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

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

IG Relationships

The IG is based on core FHIR R4.

Timelines

STU ballot in the January 2020 cycle