CARIN RTPBC FHIR IG Proposal
- 1 CARIN Real-time Pharmacy Benefit Check
- 1.1 Owning Workgroup
- 1.2 Committee Approval Date:
- 1.3 Publishing Lead
- 1.4 Contributing or Reviewing Work Groups
- 1.5 FHIR Development Project Insight ID
- 1.6 Scope of coverage
- 1.7 Content location
- 1.8 Proposed IG realm and code
- 1.9 Maintenance Plan
- 1.10 Short Description
- 1.11 Long Description
- 1.12 Involved parties
- 1.13 Expected implementations
- 1.14 Content sources
- 1.15 Example Scenarios
- 1.16 IG Relationships
- 1.17 Timelines
- 1.18 FMG Notes
CARIN Real-time Pharmacy Benefit Check
HL7 Pharmacy WG
Committee Approval Date:
Frank McKinney (email@example.com)
Contributing or Reviewing Work Groups
HL7 Financial Management WG
FHIR Development Project Insight ID
To be added
Scope of coverage
This is a guide for implementing the consumer-focused real-time pharmacy benefit check (consumer RTPBC) using FHIR R4.
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. Is is further limited to commercially available medication products that are not compounded at the pharmacy.
The guide is for use in the United States only.
To be updated
Proposed IG realm and code
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.
CARIN RTPBC FHIR Implementation Guide
With consumer RTPBC, a patient can learn how their medications will be covered at the pharmacy, including out of pocket costs, prior authorization requirements and any limits 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.
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.
The aim of the CARIN Alliance is to advance the ability for consumers and their authorized caregivers to easily get, use, and share their digital health information when, where, and how they want to achieve their goals.
CARIN Alliance members including health plans, pharmacy benefit managers and consumer application vendors.
The CARIN consumer RTPBC process is an adaptation of the NCPDP provider-focused Real-time Pharmacy Benefit Check transactions. The CARIN Alliance is consulting NCPDP in addition the HL7 Pharmacy and Financial Management workgroups in process of developing this guide.
Retrieve patient-specific cost and coverage information for a medication product
The IG is based on FHIR R4.
TO BE REVIEWED / ADJUSTED: Informative Jan 2020 Ballot STU May 2020 Ballot