Real-time prescription benefit

• The estimated cost information included in the RTPBRequest and RTPBResponse transactions only pertains to patient out-of-pocket costs. Prescribers using Real-Time Benefit Tools (RTBTs) that implement the NCPDP RTPB standard, version 13, have the capability to request and receive information on overall costs.  This includes fields such as “estimated net plan cost” and “estimated combined plan and patient savings” but only when allowed and provided by the plan. [see also 90 FR 37154]
• There are no restrictions to the scope of products included in this criterion, allowing coverage of any pharmacy benefit products (e.g., medications, vaccines, supplies, devices). [see also 90 FR 37157]
• Developers must support transactions with at least one version of RxNorm.

Technical outcome – Enable a user to perform real-time prescription benefit (RTPB) requests and receive RTPB information using the XML format in accordance with the NCPDP Real-Time Prescription Benefit Standard Implementation Guide v13, RxNorm and NDC.

Clarifications:

• A Health IT Module must enable a user to use conduct transactions in accordance with one of the versions of RxNorm “at a minimum” to ensure alignment with the existing minimum standards code set policy in the Certification Program in 45 CFR 170.555. [see also 90 FR 37158]
• RTPBError transactions are not a requirement under this criterion as error handling is built into the RTPBResponse transaction. [see also 90 FR 37154]

Technical outcome – Display to a user in human readable format patient-specific prescription benefit information, estimated cost information, and alternative products, in accordance with the NCPDP Real-Time Prescription Benefit Standard Implementation Guide v13.

Clarifications:

• ASTP/ONC previously referred to “alternative products” as “therapeutic alternatives” in earlier proposed rules. However, to be consistent with NCPDP terminology, regulation was finalized to reference “alternative products.” [see also 90 FR 37154]
• Developers have flexibility in determining how to present information to users.