RTPBResponse Best Practices

alternatives alternatives (maximum of 5 allowed) should be sent in priority order, from most preferred to least preferred when available, diagnosis codes sent in the rtpbrequest (requestedproduct/diagnosis) should be considered to provide most therapeutically appropriate alternative medications in the rtpbresponse note before recommending an alternative medication, confirm that it aligns with the following carefully adhering to these factors better ensures patient safety and therapeutic effectiveness release mechanism maintains the same action profile (e g , long acting or short acting) therapeutic equivalence meets clinical standards for equivalence the alternative medication should match the requested medication's dosage form (e g , tablet, capsule, injection, topical, etc ) the medication strength should provide the same or equivalent dose patient specific needs accounts for allergies, co morbidities, and special considerations (age, gender, diagnosis) when the requested medication is coveredwithrestrictions due to plan limitations (e g , day supply, quantity) and reason sent is exceeds plan limit, the medication that is covered should be sent as an alternative only alternatives that are covered or coveredwithrestrictions should be sent when biosimilar/interchangeable alternative medications are available and the rtpbrequest includes a diagnosis code (requestedproduct/diagnosis), the diagnosis code should be used to better determine interchangeability of the requested medication when sending biosimilar/interchangeable medication alternatives, it is recommended to do the following use 'drug description' field to explicitly populate the biosimilar name examples clearly indicate that the medication is a biosimilar by including terms like "biosimilar" alongside the drug name (e g , "adalimumab adbm (biosimilar to humira®)") include the reference biologic's name in parentheses (e g , "biosimilar of \[reference product name]") leverage the pricingandcoverage/coveragestatusmessage free text field to communicate that the alternative medication is a biosimilar/interchangeable medication examples coverage transparency free text example "this is a biosimilar medication" cost comparison free text example "lower cost alternative to \[reference biologic name] " provide medication alternatives in the rtpbresponse only when the requestedproduct/dispensedaswrittenproductselectioncode cove value is set to ‘0' or '2 9’ (medication substitutions are allowed) alternative pharmacies when the requested medication is not covered at the requested pharmacy, it is recommended to send an alternative covered pharmacy presenting an alternative covered pharmacy supports prescribers in selecting a fill location that avoids coverage issues and minimizes delays for the patient quantity unit of measure the request may contain any quantity unit of measure (fmt code) that is valid it should be used when calculating pricing for a list of fmt codes, go to http //evs nci nih gov/ftp1/ncpdp/about html http //evs nci nih gov/ftp1/ncpdp/about html this list should be updated on a monthly basis use the ncpdp quantityunitofmeasure terminology rows from the downloaded data quantityunitofmeasure/code should mirror the requested quantity unit of measure if the requested quantity unit of measure is already a billable code pricing when estimated patient financial responsibility is available, it should be sent in the rtpbresponse to allow for pointed medication cost information review between provider and patient note if the requested medication can be priced/covered under any condition (e g , prior authorization approval), a price should be sent (assuming condition(s) are met) if a medication cannot be priced under any condition, price is not expected requested medication, quantity, quantity unit of measure, days supply, and pharmacy ncpdp id pricing coverage should be listed as the first drug in the rtpbresponse it is recommended to avoid using any default prices for medications when rtpbrequests contain billable quantity unit of measure codes, these codes should be utilized when calculating medication prices the dayssupply value should be sent every time pricing is provided prior authorization communication when prior authorization requirements are known for requested and alternative medications, the applicable coveragerestrictioncode should be sent for the medication(s) prior authorization communication should consider medical necessity, prior treatment, clinical indications, and total cost of therapy the epaenabled flag should be returned only when a prior authorization is required for a medication, and the pbm/payer is able to accept an electronic submission to request a prior authorization if a medication requires a prior authorization on the date of the rtpbrequest, the coveragerestrictioncode of "75" should be sent if the medication requires a prior authorization, medication cost is expected and should reflect the price if/when prior authorization is approved when available, diagnosis codes sent in the rtpbrequest (requestedproduct/diagnosis) should be considered to provide the most accurate prior authorization requirements for target and alternative medications in the rtpbresponse in cases where a prior authorization has already been approved for the requested drug, the response should indicate coverage by returning a coveragestatuscode of cc (covered) along with a coveragerestrictioncode of ab8 (prior authorization approval on file) use of coveragerestrictioncode 75 (prior authorization required) is not recommended in this situation because provider vendors may interpret this code as a trigger to queue prior authorization workflows this approach notifies the prescriber that a prior authorization is already on file, helping avoid unnecessary requests that could delay prescription pickup general there may be instances where multiple rtpbrequests are sent in parallel to gather additional information for the provider it is recommended to avoid rate limiting to allow for successful message processing the pbm/payer should echo the requested medication (e g , drug description, quantity, days supply, pharmacy, quantityunitofmeasure (if billable), etc ) in the rtpbresponse to ensure the requester can validate rtpbresponse content and to ensure the information is displayed to the requester when possible, requested over the counter (otc) medications should be processed as prescription medications it is recommended for the pbm/payer to echo the ndc when possible if the ndc that the pbm/payer received cannot be processed, it is permissible to send a different representative ndc if additional context and messaging is needed, it is recommended to avoid the use of pharmacy adjudication reject language clear and complete text messages present as more useful and provider friendly when making medication decisions it is recommended to avoid sending ncpdp codes within free text fields (e g , reject codes should be sent in the discreet rejectcode field, and coverage status codes should be sent in the discreet coveragestatuscode field )when used, free text fields (e g , notprocessed/note, processed/note, pricingandcoverage/coveragestatusmessage) should be used to expand upon related codified values free text should not simply reiterate related codified value translations note in applicable situations (e g , antibiotics that exceed 21 day supply), extended day supplies may be removed and may result in an error back to the requester