Documentation
¶
Overview ¶
Package rtpb answers NCPDP Real-Time Prescription Benefit requests from a formulary: what a drug will cost this member at this pharmacy, whether it needs a prior authorization or a step first, and which alternatives cost less.
CMS-0062-P proposes RTPB for impacted payers from 1 October 2027. The XML is NCPDP RTPB v13 (PBv13). NCPDP's schema is licensed, so element names and order follow the public Surescripts RTPB examples and NCPDP's public RTPB Implementation Recommendations (coverage restriction codes and the coverage status each maps to); a response is not checked against the XSD here, and a network certification is where that happens.
Index ¶
Constants ¶
const ( RestrictionPriorAuth = "75" // Prior Authorization Required RestrictionPlanLimits = "76" // Plan Limitations Exceeded RestrictionNotCovered = "70" // Product/Service Not Covered - Plan/Benefit Exclusion RestrictionStepTherapy = "608" // Step Therapy, Alternate Drug Therapy Required Prior To Use Of Submitted Product RestrictionDaysSupply = "7X" // Days Supply Exceeds Plan Limitation RestrictionPAOnFile = "AB8" // Prior Authorization Approval on File StatusCovered = "CC" StatusCoveredRestrictions = "CR" StatusNotCovered = "NC" )
Coverage restriction codes (NCPDP ECL, F12-Y8), and the coverage status each maps to (F13-YA) by NCPDP's RTPB Implementation Recommendations.
const ( RejectCardholder = "52" // Non-Matched Cardholder ID RejectProduct = "54" // Non-Matched Product/Service ID Number RejectQuantity = "E7" // M/I Quantity Dispensed RejectDaysSupply = "19" // M/I Days Supply )
Reject codes (NCPDP Telecom 511-FB) for a request that cannot be priced at all.
const Version = "PBv13"
Version is the RTPB version this package reads and writes.
Variables ¶
This section is empty.
Functions ¶
Types ¶
type Answer ¶
type Answer struct {
Processed bool `json:"processed"`
Reject string `json:"reject,omitempty"`
Note string `json:"note"`
Plan string `json:"plan,omitempty"`
Requested *Priced `json:"requested,omitempty"`
Alternatives []Priced `json:"alternatives,omitempty"`
}
Answer is what the formulary says about one request, before it is written as XML: for the GUI and for tests.
type Header ¶
type Header struct {
To Party `xml:"To"`
From Party `xml:"From"`
MessageID string `xml:"MessageID"`
RelatesToMessageID string `xml:"RelatesToMessageID,omitempty"`
SentTime string `xml:"SentTime"`
}
Header is the RTPB header.
type Options ¶
type Options struct {
// Member finds a member's plan id in the FHIR store, or "".
Member func(id string) string
// PAOnFile says whether the member has an approved prior authorization for the drug (RxNorm) in force.
PAOnFile func(member, rxnorm string) bool
}
Options are what answering needs besides the formulary.
type Party ¶
type Party struct {
Primary ID `xml:"Primary"`
Secondary *ID `xml:"Secondary,omitempty"`
Tertiary *ID `xml:"Tertiary,omitempty"`
}
Party is a To or From.
type Pharmacy ¶
type Pharmacy struct {
PharmacyType string `xml:"PharmacyType,omitempty"`
Identification struct {
NCPDPID string `xml:"NCPDPID,omitempty"`
NPI string `xml:"NPI,omitempty"`
} `xml:"Identification"`
BusinessName string `xml:"BusinessName,omitempty"`
}
Pharmacy is where the prescription would be filled.
type Priced ¶
type Priced struct {
NDC string `json:"ndc"`
RxNorm string `json:"rxnorm"`
Description string `json:"description"`
Tier string `json:"tier"`
Status string `json:"coverageStatus"`
Formulary string `json:"formularyStatus"`
Restrictions []string `json:"restrictions,omitempty"`
// PatientPays is the member's estimated share in dollars; nil when it cannot be stated (a coinsurance without a cost).
PatientPays *float64 `json:"patientPays,omitempty"`
PlanCost *float64 `json:"planCost,omitempty"`
Message string `json:"message"`
Quantity string `json:"quantity"`
Unit string `json:"unit"`
Days int `json:"days"`
Benefit string `json:"benefit"`
}
Priced is one drug's coverage and cost.
type Product ¶
type Product struct {
DrugCoded struct {
NDC string `xml:"NDC"`
} `xml:"DrugCoded"`
}
Product names a drug by NDC.
type Quantity ¶
type Quantity struct {
Value string `xml:"Value"`
CodeListQualifier string `xml:"CodeListQualifier"`
QuantityUnitOfMeasure struct {
Code string `xml:"Code"`
} `xml:"QuantityUnitOfMeasure"`
}
Quantity is an amount and its unit.
type Request ¶
type Request struct {
XMLName xml.Name `xml:"Message"`
Header Header `xml:"RTPBHeader"`
Body struct {
Request *RequestBody `xml:"RTPBRequest"`
} `xml:"RTPBBody"`
}
Request is an RTPBRequest message, as much of it as answering needs.
type RequestBody ¶
type RequestBody struct {
Patient struct {
Name struct {
LastName string `xml:"LastName"`
FirstName string `xml:"FirstName"`
} `xml:"Name"`
DateOfBirth string `xml:"DateOfBirth"`
StateProvince string `xml:"StateProvince"`
PostalCode string `xml:"PostalCode"`
} `xml:"Patient"`
BenefitsCoordination struct {
PBMMemberID string `xml:"PBMMemberID"`
GroupID string `xml:"GroupID"`
} `xml:"BenefitsCoordination"`
RequestedProduct struct {
Product Product `xml:"Product"`
Quantity *Quantity `xml:"Quantity"`
DaysSupply string `xml:"DaysSupply"`
Diagnosis []struct {
Code string `xml:"Code"`
Qualifier string `xml:"Qualifier"`
} `xml:"Diagnosis"`
} `xml:"RequestedProduct"`
Prescriber struct {
Identification struct {
NPI string `xml:"NPI"`
} `xml:"Identification"`
} `xml:"Prescriber"`
Pharmacy *Pharmacy `xml:"Pharmacy"`
}
RequestBody is the RTPBRequest.
Source Files