Message Examples

<?xml version="1.0" encoding="utf-8"?>
<Message RTPBDatatypesVersion="PBv13" RTPBTransportVersion="PBv13" RTPBTransactionDomain="RTPB" 
RTPBTransactionVersion="PBv13" RTPBStructuresVersion="PBv13" RTPBECLVersion="PBv13" RTPBVersion="PBv13">
    <RTPBHeader>
        <To>
            <Primary>
                <Identification>017010</Identification>
                <Qualifier>IIN</Qualifier>
            </Primary>
            <Secondary>
                <Identification>0215COMM</Identification>
                <Qualifier>PCN</Qualifier>
            </Secondary>
            <Tertiary>
                <Identification>123456789</Identification>
                <Qualifier>PY</Qualifier>
            </Tertiary>
        </To>
        <From>
            <Primary>
                <Identification>123456789</Identification
                <Qualifier>P</Qualifier>
            </Primary>
        </From>
        <MessageID>316c5d95571c4f35acdb9fb5324181e7</MessageID>
        <RelatesToMessageID>NewRxMessageID</RelatesToMessageID>
        <SentTime>2025-02-20T10:10:03.9247997Z</SentTime>
        <SoftwareSenderCertificationID>123456789</SoftwareSenderCertificationID>
    </RTPBHeader>
    <RTPBBody>
         <RTPBRequest>
             <Patient>
                 <Name>
                     <LastName>KING</LastName>
                     <FirstName>ABE</FirstName>
                 </Name>
                 <SexAndGender>
                     <AdministrativeGender>M</AdministrativeGender>
                 </SexAndGender>
                 <DateOfBirth>1955-06-12</DateOfBirth>
                 <StateProvince>AZ</StateProvince>
                 <PostalCode>97884</PostalCode>
                 <CountryCode>US</CountryCode>
                 <Extension name="City" url="http://surescripts.com/extensions/RTPBRequest/Patient/City">
                     <String>WARREN</String>
                 </Extension>
             </Patient>
             <BenefitsCoordination>
                 <GroupID>1234</GroupID>
            </BenefitsCoordination>
             <RequestedProduct>
                 <Product>
                     <DrugCoded>
                         <NDC>00456401001</NDC>
                     </DrugCoded>
                 </Product>
                 <Quantity>
                     <Value>30</Value>
                     <CodeListQualifier>38</CodeListQualifier>
                     <QuantityUnitOfMeasure>
                         <Code>C28254</Code>
                     </QuantityUnitOfMeasure>
                 </Quantity>
                 <DaysSupply>30</DaysSupply>
             </RequestedProduct>
             <Prescriber>
                 <Identification>
                     <NPI>1234567890</NPI>
                 </Identification>
                 <LastName>Unknown</LastName>
             </Prescriber>
             <Pharmacy>
                 <Identification>
                     <NCPDPID>9999999</NCPDPID>
                     <NPI>1234567890</NPI>
                 </Identification>
                 <BusinessName>PharmacyBusinessName</BusinessName>
                 <PrimaryTelephoneNumber>5556667777</PrimaryTelephoneNumber>
             </Pharmacy>
         </RTPBRequest>
     </RTPBBody>
 </Message>

<?xml version="1.0" encoding="utf-8"?>
<Message RTPBDatatypesVersion="PBv13" RTPBTransportVersion="PBv13" RTPBTransactionDomain="RTPB" RTPBTransactionVersion="PBv13" 
RTPBStructuresVersion="PBv13" RTPBECLVersion="PBv13" RTPBVersion="PBv13">
<RTPBHeader>
    <To>
      <Primary>
        <Identification>D00000000123597</Identification>
        <Qualifier>P</Qualifier>
      </Primary>
    </To>
    <From>
      <Primary>
        <Identification>434257</Identification>
        <Qualifier>IIN</Qualifier>
      </Primary>
      <Secondary>
        <Identification>012345</Identification>
        <Qualifier>PCN</Qualifier>
      </Secondary>
      <Tertiary> 
        <Identification>D00000000478396</Identification> 
        <Qualifier>PY</Qualifier> 
      </Tertiary> 
    </From>
    <MessageID>SomeGeneratedId</MessageID>
    <RelatesToMessageID>RequestIdSentFromEHR</RelatesToMessageID>
    <SentTime>2025-03-12T10:10:02.9587124Z</SentTime>
  </RTPBHeader>
  <RTPBBody>
    <RTPBResponse>
      <Response>
        <Processed>
          <Note>Success</Note>
        </Processed>
      </Response>
        <Extension name=" BenefitsCoordination " url="http://surescripts.com/extensions/
BenefitsCoordination">
          <Extension name="PayerName" url="PayerName">
            <String>123456789</String>
          </Extension>
          <Extension name="ProcessorIndentificationNumber" url="ProcessorIndentificationNumber">
            <String>123456789</String>
          </Extension>
          <Extension name="IINNumber" url="IINNumber">
            <String>123456789</String>
          </Extension>
          <Extension name="CardholderID" url="CardholderID">
            <String>123456789</String>
          </Extension>
          <Extension name="GroupID" url="GroupID">
            <String>123456789</String>
          </Extension>
          <Extension name="GroupName" url="GroupName">
            <String>123456789</String>
          </Extension>
          <Extension name="PBMMemberID" url="PBMMemberID">
            <String>123456789</String>
          </Extension>
        </Extension>
      <ResponseProduct>
        <Product>
          <DrugCoded>
            <NDC>00456401001</NDC>
          </DrugCoded>
        </Product>
        <DrugDescription>Celexa 10mg Tablet</DrugDescription>
        <Quantity>
          <Value>30</Value>
          <CodeListQualifier>38</CodeListQualifier>
          <QuantityUnitOfMeasure>
            <Code>C28254</Code>
          </QuantityUnitOfMeasure>
        </Quantity>
        <PricingAndCoverages>
          <Pharmacy>
            <PharmacyType>R</PharmacyType>
            <Identification>
              <NCPDPID>9999999</NCPDPID>
              <NPI>1234567890</NPI>
            </Identification>
            <BusinessName>PharmacyBusinessName</BusinessName>
          </Pharmacy>
          <PricingAndCoverage>
            <PricingAndCoverageIndicator>R</PricingAndCoverageIndicator>
            <CoverageStatusCode>CC</CoverageStatusCode>
            <FormularyStatus>U</FormularyStatus>
            <Quantity>
              <Value>30</Value>
              <CodeListQualifier>38</CodeListQualifier>
              <QuantityUnitOfMeasure>
                <Code>C28254</Code>
              </QuantityUnitOfMeasure>
            </Quantity>
            <DaysSupply>30</DaysSupply>
            <EstimatedPatientFinancialResponsibility>703.39</EstimatedPatientFinancialResponsibility>
            <PatientPayComponent>
              <PatientPayComponentQualifier>01</PatientPayComponentQualifier>
              <PatientPayComponentAmount>0.3</PatientPayComponentAmount>
            </PatientPayComponent>
            <RemainingDeductibleAmount>40</RemainingDeductibleAmount>
            <EstimatedNetPlanCost>3176.67</EstimatedNetPlanCost>
          </PricingAndCoverage>
        </PricingAndCoverages>
        <PricingAndCoverages>
          <Pharmacy>
            <PharmacyType>R</PharmacyType>
            <Identification>
              <NCPDPID>9999999</NCPDPID>
              <NPI>1234567890</NPI>
            </Identification>
            <BusinessName>PharmacyBusinessName</BusinessName>
          </Pharmacy>
          <PricingAndCoverage>
            <PricingAndCoverageIndicator>D</PricingAndCoverageIndicator>
            <CoverageStatusCode>CR</CoverageStatusCode>
            <FormularyStatus>U</FormularyStatus>
            <Quantity>
              <Value>90</Value>
              <CodeListQualifier>38</CodeListQualifier>
              <QuantityUnitOfMeasure>
                <Code>C28254</Code>
              </QuantityUnitOfMeasure>
            </Quantity>
            <DaysSupply>90</DaysSupply>
            <CoverageRestriction>
              <CoverageRestrictionCode>7X</CoverageRestrictionCode>
            </CoverageRestriction>
          </PricingAndCoverage>
        </PricingAndCoverages>
      </ResponseProduct>
      <ResponseAlternativeProduct>
        <Product>
          <DrugCoded>
            <NDC>00185037101</NDC>
          </DrugCoded>
        </Product>
        <DrugDescription>FirstAlternate</DrugDescription>
        <PricingAndCoverages>
          <Pharmacy>
            <PharmacyType>R</PharmacyType>
            <Identification>
              <NCPDPID>9999999</NCPDPID>
              <NPI>1234567890</NPI>
            </Identification>
            <BusinessName>PharmacyBusinessName</BusinessName>
          </Pharmacy>
          <PricingAndCoverage>
            <PricingAndCoverageIndicator>R</PricingAndCoverageIndicator>
            <CoverageStatusCode>CC</CoverageStatusCode>
            <FormularyStatus>U</FormularyStatus>
            <Quantity>
              <Value>30</Value>
              <CodeListQualifier>38</CodeListQualifier>
              <QuantityUnitOfMeasure>
                <Code>C28254</Code>
              </QuantityUnitOfMeasure>
            </Quantity>
            <DaysSupply>30</DaysSupply>
            <EstimatedPatientFinancialResponsibility>3.6</EstimatedPatientFinancialResponsibility>
          </PricingAndCoverage>
        </PricingAndCoverages>
      </ResponseAlternativeProduct>
      <ResponseAlternativeProduct>
        <Product>
          <DrugCoded>
            <NDC>00378700110</NDC>
          </DrugCoded>
        </Product>
        <DrugDescription>SecondAlternate</DrugDescription>
        <PricingAndCoverages>
          <Pharmacy>
            <PharmacyType>R</PharmacyType>
            <Identification>
              <NCPDPID>9999999</NCPDPID>
              <NPI>1234567890</NPI>
            </Identification>
            <BusinessName>PharmacyBusinessName</BusinessName>
          </Pharmacy>
          <PricingAndCoverage>
            <PricingAndCoverageIndicator>R</PricingAndCoverageIndicator>
            <CoverageStatusCode>CC</CoverageStatusCode>
            <FormularyStatus>U</FormularyStatus>
            <Quantity>
              <Value>30</Value>
              <CodeListQualifier>38</CodeListQualifier>
              <QuantityUnitOfMeasure>
                <Code>C28254</Code>
              </QuantityUnitOfMeasure>
            </Quantity>
            <DaysSupply>30</DaysSupply>
            <EstimatedPatientFinancialResponsibility>3.6</EstimatedPatientFinancialResponsibility>
          </PricingAndCoverage>
        </PricingAndCoverages>
      </ResponseAlternativeProduct>
    </RTPBResponse>
  </RTPBBody>
</Message>