Unclear how cash prices will be determined and if this information will even be accessible by the patient facing tool.

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    • Type: Change Request
    • Resolution: Persuasive with Modification
    • Priority: Medium
    • US CARIN Real-time Pharmacy Benefit Check (RTPBC) (FHIR)
    • Pharmacy
    • Use Cases
    • Guidance - Use Cases
    • Hide

      Resolution: Add guidance clarifying that cash pricing is expected to be returned primarily by discount pricing sources and not payers.

      [To be included in a new Implementation Guidance page]:
      Cash prices in the response
      The Patient Pay Type value set specifies different patient costs that may be returned in an RTPBC response. Included are:
      - Costs related to the patient's insurance coverage, such as copay, coinsurance and deductible amounts. These are expected to be returned when the responder is an insurer or their agent.
      - Cash prices and discounts available when the patient opts to pay cash for their prescription rather than submitting through their insurance. These types are expected to be returned when the responder is a discount pricing source or other responder that is not the patient's insurer.

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      Resolution: Add guidance clarifying that cash pricing is expected to be returned primarily by discount pricing sources and not payers. [To be included in a new Implementation Guidance page] : Cash prices in the response The Patient Pay Type value set specifies different patient costs that may be returned in an RTPBC response. Included are: - Costs related to the patient's insurance coverage, such as copay, coinsurance and deductible amounts. These are expected to be returned when the responder is an insurer or their agent. - Cash prices and discounts available when the patient opts to pay cash for their prescription rather than submitting through their insurance. These types are expected to be returned when the responder is a discount pricing source or other responder that is not the patient's insurer.
    • Scott Robertson / Frank McKinney : 15-0-0
    • Clarification
    • Non-substantive
    • 0.1.0

      How is cash price information going to be gathered? (not sure if this is a comment to actually make, but this is a concern for the provider focused RTPB tools) NCPDP folk are concerned about being able to access this info and share it with providers since this kind of pricing information is sometimes kept confidential, so I am wondering what the plan is for the patient-facing tool to be able to display this info. At this point I don’t think the cash price is going to be included in the NCPDP prescriber-facing tool, which again raises concerns about the alignment of data provided to physicians and patients.

      What is going to be the source of “discount prices” shown to the patient? GoodRx? Pharmaceutical manufacturer patient assistance programs? This is not clear. Again, it’s concerning that this information is being given to patients and not physicians.

      Existing Wording:

      The goal of the consumer-focused real-time pharmacy benefit check (consumer RTPBC) is to inform a patient of the cost and insurance coverage related to medications they’ve been prescribed. This involves two key aspects:

      Use case 1: Enable the patient to find out how their medications will be covered by their insurance, including out of pocket costs and any coverage restrictions or requirements that might apply

      Use case 2: Help the patient discover discount pricing available for the medication\.

            Assignee:
            Unassigned
            Reporter:
            Celine Lefebvre
            Celine Lefebvre
            Watchers:
            1 Start watching this issue

              Created:
              Updated:
              Resolved: