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  1. FHIR Specification Feedback
  2. FHIR-26500

The goals of this standard can already be accomplished by the NCPDP standard…

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    • Type: Change Request
    • Status: Resolved - change required (View Workflow)
    • Priority: Medium
    • Resolution: Not Persuasive with Modification
    • Specification:
      US CARIN Real-time Pharmacy Benefit Check (RTPBC) (FHIR)
    • Work Group:
      Pharmacy
    • Related Page(s):
      Table of Contents
    • Grouping:
    • Resolution Description:
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      Add content to the Consumer vs provider RTPBC page clarifying the rationale for establishing a separate exchange targeted at the consumer use case.

      Why a dedicated consumer-focused RTPBC solution?
      The aim of this implementation guide is to provide the information a patient needs to understand how their prescription will be covered by their insurance, and the out-of-pocket costs they might face—whether they use their insurance or if they choose to pay cash.

      Focusing on the consumer's needs brings additional information and participants into scope, such as real-world cash price comparisons from pricing source entities, and discounts available to the patient through manufacturer programs.

      The consumer focus also sets a different frame for the information to be returned by an insurer. For example, differences in copay costs between nearby in-network and out-of-network pharmacies become a high priority, and characterizing coverage restrictions and limits in a way that is clear and meaningful to a typical patient becomes essential.

      The consumer-focused RTPBC IG establishes a vehicle for this information exchange that can evolve independently over time to best meet the needs of the patient.

      Show
      Add content to the Consumer vs provider RTPBC page clarifying the rationale for establishing a separate exchange targeted at the consumer use case. Why a dedicated consumer-focused RTPBC solution? The aim of this implementation guide is to provide the information a patient needs to understand how their prescription will be covered by their insurance, and the out-of-pocket costs they might face—whether they use their insurance or if they choose to pay cash. Focusing on the consumer's needs brings additional information and participants into scope, such as real-world cash price comparisons from pricing source entities, and discounts available to the patient through manufacturer programs. The consumer focus also sets a different frame for the information to be returned by an insurer. For example, differences in copay costs between nearby in-network and out-of-network pharmacies become a high priority, and characterizing coverage restrictions and limits in a way that is clear and meaningful to a typical patient becomes essential. The consumer-focused RTPBC IG establishes a vehicle for this information exchange that can evolve independently over time to best meet the needs of the patient.
    • Resolution Vote:
      Frank McKinney / Daniel Zhang : 12-0-0
    • Change Category:
      Clarification
    • Change Impact:
      Non-substantive
    • Applied for Version:
      0.1.0

      Description

      The goals of this standard can already be accomplished by the NCPDP standard. Creation of a new standard (particularly if it will be named in regulation in addition to NCPDP) will only result in unnecessary extra work from vendors to support the same thing two different ways.

      Existing Wording:

      Relationship to the NCPDP provider-focused RTPBC transactions

      This initial release of the consumer RTPBC profile seeks to include the coverage and cost information that’s the most useful and meaningful to patients. As a result, certain content in the provider-centric NCPDP RTPBC standard is not included here. Additional content could potentially be added in a later effort. (See Consumer vs provider RTPBC for content comparison.)

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              Assignee:
              Unassigned Unassigned
              Reporter:
              dzhang Daniel Zhang
              Request in-person:
              Daniel Zhang
              Watchers:
              1 Start watching this issue

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                Resolved:
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