Message Examples
4 min
Note: Examples are intended for schema illustration purposes only. The data supplied in the examples may not be clinically accurate.
RTPBRequest Example
Note: This example includes diagnosis information.
<?xml version="1.0" encoding="UTF-8"?>
<Message RTPBDatatypesVersion="PBv13" RTPBTransportVersion="PBv13" RTPBTransactionDomain="RTPB" RTPBTransactionVersion="PBv13"
RTPBStructuresVersion="PBv13" RTPBECLVersion="PBv13" xsi:noNamespaceSchemaLocation="RTPBtransport.xsd" RTPBVersion="PBv13"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<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>D00000000123597</Identification>
<Qualifier>D</Qualifier>
</Primary>
</From>
<MessageID>SomeGeneratedEHRId</MessageID>
<RelatesToMessageID>EligibilityIdObtainedFromEHR</RelatesToMessageID>
<SentTime>2024-03-12T10:10:02.9587124Z</SentTime>
<SoftwareSenderCertificationID>2233445566</SoftwareSenderCertificationID>
</RTPBHeader>
<RTPBBody>
<RTPBRequest>
<Patient>
<Name>
<LastName>WHITE</LastName>
<FirstName>MARY</FirstName>
</Name>
<SexAndGender>
<AdministrativeGender>F</AdministrativeGender>
</SexAndGender>
<DateOfBirth>1935-10-01</DateOfBirth>
<StateProvince>MD</StateProvince>
<PostalCode>20850</PostalCode>
<Extension name="City" url="http://surescripts.com/extensions/RTPBRequest/Patient/City">
<String>Annapolis</String>
</Extension>
</Patient>
<BenefitsCoordination>
<PBMMemberID>123456789</PBMMemberID>
</BenefitsCoordination>
<RequestedProduct>
<Product>
<DrugCoded>
<NDC>00456140230</NDC>
</DrugCoded>
</Product>
<Quantity>
<Value>30</Value>
<CodeListQualifier>38</CodeListQualifier>
<QuantityUnitOfMeasure>
<Code>C48542</Code>
</QuantityUnitOfMeasure>
</Quantity>
<DaysSupply>30</DaysSupply>
<DispensedAsWrittenProductSelectionCode>0</DispensedAsWrittenProductSelectionCode>
<Diagnosis>
<Code>DiagnosisCode1</Code>
<Qualifier>ABF</Qualifier>
</Diagnosis>
<Diagnosis>
<Code>DiagnosisCode2</Code>
<Qualifier>LD</Qualifier>
</Diagnosis>
</RequestedProduct>
<Prescriber>
<Identification>
<NPI>2256487127</NPI>
</Identification>
<LastName>JONES</LastName>
</Prescriber>
<Pharmacy>
<Identification>
<NCPDPID>0618097</NCPDPID>
<NPI>2123112346</NPI>
</Identification>
<BusinessName>ELM STREET PHARMACY</BusinessName>
<PrimaryTelephoneNumber>3015550120</PrimaryTelephoneNumber>
</Pharmacy>
</RTPBRequest>
</RTPBBody>
</Message>RTPBResponse Example
<?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>D</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>2024-03-12T10:10:02.9587124Z</SentTime>
</RTPBHeader>
<RTPBBody>
<RTPBResponse>
<Response>
<Processed>
<Note>Success</Note>
</Processed>
</Response>
<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>3412131</NCPDPID>
<NPI>1234567890</NPI>
</Identification>
<BusinessName>UNKNOWN</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>M</PharmacyType>
<Identification>
<NCPDPID>2623735</NCPDPID>
<NPI>1234567890</NPI>
</Identification>
<BusinessName>UNKNOWN</BusinessName>
</Pharmacy>
<PricingAndCoverage>
<PricingAndCoverageIndicator>M</PricingAndCoverageIndicator>
<CoverageStatusCode>CR</CoverageStatusCode>
<FormularyStatus>U</FormularyStatus>
<Quantity>
<Value>90</Value>
<CodeListQualifier>38</CodeListQualifier>
<QuantityUnitOfMeasure>
<Code>C28254</Code>
</QuantityUnitOfMeasure>
</Quantity>
<DaysSupply>90</DaysSupply>
<EstimatedPatientFinancialResponsibility>766.26</EstimatedPatientFinancialResponsibility>
<RemainingDeductibleAmount>0</RemainingDeductibleAmount>
<EstimatedNetPlanCost>3209.05</EstimatedNetPlanCost>
<CoverageRestriction>
<CoverageRestrictionCode>9G</CoverageRestrictionCode>
</CoverageRestriction>
<CoverageRestriction>
<CoverageRestrictionCode>7X</CoverageRestrictionCode>
</CoverageRestriction>
<CoverageRestriction>
<CoverageRestrictionCode>608</CoverageRestrictionCode>
</CoverageRestriction>
<CoverageRestriction>
<CoverageRestrictionCode>MR</CoverageRestrictionCode>
</CoverageRestriction>
<CoverageRestriction>
<CoverageRestrictionCode>AJ</CoverageRestrictionCode>
</CoverageRestriction>
</PricingAndCoverage>
</PricingAndCoverages>
<PricingAndCoverages>
<Pharmacy>
<PharmacyType>R</PharmacyType>
<Identification>
<NCPDPID>0100949</NCPDPID>
<NPI>1234567890</NPI>
</Identification>
<BusinessName>UNKNOWN</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>3412131</NCPDPID>
<NPI>1234567890</NPI>
</Identification>
<BusinessName>UNKNOWN</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>3412131</NCPDPID>
<NPI>1234567890</NPI>
</Identification>
<BusinessName>UNKNOWN</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>Affiliated Pharmacy Request Example
<?xml version="1.0" encoding="UTF-8"?>
<Message RTPBDatatypesVersion="PBv13" RTPBTransportVersion="PBv13" RTPBTransactionDomain="RTPB" RTPBTransactionVersion="PBv13"
RTPBStructuresVersion="PBv13" RTPBECLVersion="PBv13" xsi:noNamespaceSchemaLocation="RTPBtransport.xsd" RTPBVersion="PBv13"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<RTPBHeader>
<To>
<Primary>
<Identification>S00000000000005</Identification>
<Qualifier>PY</Qualifier>
</Primary>
<Secondary>
<Identification>T00000001123020</Identification>
<Qualifier>PY</Qualifier>
</Secondary>
</To>
<From>
<Primary>
<Identification>D00000000123597</Identification>
<Qualifier>D</Qualifier>
</Primary>
</From>
<MessageID>SomeGeneratedEHRId</MessageID>
<RelatesToMessageID>EligibilityIdObtainedFromEHR</RelatesToMessageID>
<SentTime>2024-03-12T10:10:02.9587124Z</SentTime>
<SoftwareSenderCertificationID>2233445566</SoftwareSenderCertificationID>
</RTPBHeader>
<RTPBBody>
<RTPBRequest>
<Patient>
<Name>
<LastName>WHITE</LastName>
<FirstName>MARY</FirstName>
</Name>
<SexAndGender>
<AdministrativeGender>F</AdministrativeGender>
</SexAndGender>
<DateOfBirth>1935-10-01</DateOfBirth>
<StateProvince>MD</StateProvince>
<PostalCode>20850</PostalCode>
<Extension name="City" url="http://surescripts.com/extensions/RTPBRequest/Patient/City">
<String>Annapolis</String>
</Extension>
</Patient>
<BenefitsCoordination>
<PBMMemberID>123456789</PBMMemberID>
</BenefitsCoordination>
<RequestedProduct>
<Product>
<DrugCoded>
<NDC>00456140230</NDC>
</DrugCoded>
</Product>
<Quantity>
<Value>30</Value>
<CodeListQualifier>38</CodeListQualifier>
<QuantityUnitOfMeasure>
<Code>C48542</Code>
</QuantityUnitOfMeasure>
</Quantity>
<DaysSupply>30</DaysSupply>
<DispensedAsWrittenProductSelectionCode>0</DispensedAsWrittenProductSelectionCode>
</RequestedProduct>
<Prescriber>
<Identification>
<NPI>2256487127</NPI>
</Identification>
<LastName>JONES</LastName>
</Prescriber>
<Pharmacy>
<Identification>
<NCPDPID>0618097</NCPDPID>
<NPI>2123112346</NPI>
</Identification>
<BusinessName>ELM STREET PHARMACY</BusinessName>
<PrimaryTelephoneNumber>3015550120</PrimaryTelephoneNumber>
</Pharmacy>
<!-- Partner / Secondary Pharmacy -->
<Extension name="SecondaryPharmacy"
url="http://surescripts.com/extensions/RTPBRequest/SecondaryPharmacy">
<Extension name="Identification" url="Identification">
<Extension name="NCPDPID" url="NCPDPID">
<String>1375426</String>
</Extension>
<Extension name="NPI" url="NPI">
<String>2123112346</String>
</Extension>
</Extension>
<Extension name="BusinessName" url="BusinessName">
<String>RED LAKE BAND OF CHIPPEWA INDIANS</String>
</Extension>
<Extension name="PrimaryTelephoneNumber" url="PrimaryTelephoneNumber">
<String>6122223333</String>
</Extension>
</Extension>
</RTPBRequest>
</RTPBBody>
</Message>