To support reporting deductible status information at time of inquiry, NCPDP added to the RTPB Standard Version 11 (published in January 2021) situational fields for communicating Accumulated Deductible Amount (512-FC) and Remaining Deductible Amount (513-FD) for submitted and alternative products.

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Business Need/Purpose:

Used by the Provider or Pharmacist to explain the patient’s deductible status if they were to obtain the identified medication.

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Information about data elements from NCPDP Data Dictionary:

Accumulated Deductible Amount:

Amount in dollars met by the patient/family in a deductible plan.

Field length: 11; field format: s9(9)v99; Format=s$$$$$$$$$cc

RTPB EXAMPLE:

A Real-Time Prescription Benefit Request is submitted where the Patient Pay Amount is determined to be $50 and the beneficiary’s current accumulated deductible amount is $100. The Accumulated Deductible Amount returned on the RTPB response would be $150. This field would reflect: 1500{. If a subsequent RTPB request is submitted, the same current accumulated deductible amount of $100 would be leveraged.

Remaining Deductible Amount:

Amount not met by the patient/family in the deductible plan.

Field length: 11; field format: s9(9)v99; Format=s$$$$$$$$$cc

RTPB EXAMPLE:

A Real-Time Prescription Benefit Request is submitted where the Patient Pay Amount is determined to be $50 and the beneficiary’s current remaining deductible amount is $400. The Remaining Deductible Amount returned on the RTPB response would be $350 and this field would reflect: 3500{. If a subsequent RTPB request is submitted, the same current remaining deductible amount of $350 would be leveraged.

 Use of deductible accumulator data elements in RTPB Standard Implementation Guide: Required when the plan provides details of how the product could impact the patient’s deductible status.

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Pricing guidance about deductible accumulator fields from RTPB Standard Implementation Guide:

The Amount Applied to Periodic Deductible component of the Estimated Patient Financial Responsibility amount is based on plan benefit accumulators, such as the accumulated deductible and remaining deductible.  The accumulated deductible and remaining deductible amounts can be communicated in the RTPBResponse RTPB Product Segment/ResponseProduct and Response RTPB Alternative Product Segment/ResponseAlternativeProduct segments.  These are estimated amounts calculated by the pharmacy benefit manager based on the patient’s plan benefit structure and current accumulated deductible amount.  A RTPB request does not change the deductible amounts on file in the payer system. If multiple RTPB requests are submitted concurrently for a patient to a single prescription benefit plan, each is processed individually using the benefit accumulators and other financial information on file with the processor at the time of the request.  That is, the accumulator values returned on the RTPB response will only reflect the financial changes for the submitted drug and each of the alternatives versus the cumulative financial changes that occur with multiple claim billing transactions.