V2017071 SCRIPT STANDARD

V2017071 SCRIPT STANDARD
EXAMPLES GUIDE
VERSION 13
This document provides examples for the specified version of the SCRIPT Standard xml-based
messages.
July 2018
National Council for Prescription Drug Programs

9240 East Raintree Drive
Scottsdale, AZ 85260
Phone: (480) 477-1000

Fax: (480) 767-1042
e-mail: ncpdp@ncpdp.org
http: www.ncpdp.org
V20170714 SCRIPT Standard Examples Guide
Version – 13
COPYRIGHT (©) National Council for Prescription Drug Programs, Inc.
2018
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NOTICE: In addition, this NCPDP Standard contains certain data fields and elements that may be completed by users with the
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Published by:
National Council for Prescription Drug Programs
Publication History:
Version 10 - July 2017

Version 11 – March 2018
Version 12 – May 2018
Version 13 – July 2018
V13
*** OFFICIAL RELEASE***
National Council for Prescription Drug Programs, Inc.
Copyrighted Materials - See Copyright Statement for Allowed Use
2
TABLE OF CONTENTS
1. TRANSMISSION EXAMPLES ..............................................................................................5
1.1 EXAMPLE 1. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY (VIA A MAILBOX) ........... 8
1.2 EXAMPLE 2. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY (DIRECT CONNECT) ...... 21
1.3 EXAMPLE 3. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY WITH A RETURN RECEIPT
REQUESTED ................................................................................................................................... 27
1.4 EXAMPLE 4. PRESCRIPTION CHANGE TRANSACTION (VIA MAILBOX)............................................. 44
1.5 EXAMPLE 5. PRESCRIPTION CHANGE REQUEST (VIA DIRECT CONNECT) ........................................ 64
1.6 EXAMPLE 6. PHARMACY REQUESTING A RENEWAL AUTHORIZATION FOR 4 ADDITIONAL DISPENSINGS
FROM A PRESCRIBER AND PRESCRIBER RESPONDING ........................................................................... 74
1.7 EXAMPLE 7. RENEWAL PRESCRIPTION TRANSACTION WITH RETURN RECEIPT REQUESTED ............... 85
1.8 EXAMPLE 8. RENEWAL PRESCRIPTION TRANSACTION - PATIENT NO LONGER UNDER PRESCRIBER’S
CARE 92
1.9 EXAMPLE 9. NEW PRESCRIPTION WHICH IS A FREE/DISCOUNTED SAMPLE ................................... 96
1.10 EXAMPLE 10. PRESCRIPTION CHANGE TRANSACTION FOR THERAPEUTIC INTERACTION (VIA DIRECT
CONNECT) ..................................................................................................................................... 97
1.11 EXAMPLE 11. INFORM PRESCRIBER A PRESCRIPTION HAS BEEN DISPENSED (VIA DIRECT CONNECT)
108
1.12 EXAMPLE 12. INFORM PRESCRIBER A PRESCRIPTION HAS NOT BEEN DISPENSED AND WILL BE
RETURNED TO STOCK .................................................................................................................... 115
1.13 EXAMPLE 13. NOTIFY PRESCRIBER A PRESCRIPTION HAS BEEN PARTIALLY DISPENSED (VIA DIRECT
CONNECT) ................................................................................................................................... 116
1.14 EXAMPLE 14: RXFILL - DISPENSED PROFILE MEDICATION (FROM PHARMACY TO LTPAC FACILITY) 128
1.15 EXAMPLE 15. CANCEL A PRESCRIPTION PREVIOUSLY SENT TO THE PHARMACY ........................ 132
1.16 EXAMPLE 16. PHARMACY REQUESTS ALTERNATIVE DRUG TO PRESCRIBED .............................. 141
1.17 EXAMPLE 17. PRESCRIPTION CHANGE REQUEST FROM PHARMACY FOR PRIOR AUTHORIZATION
(EXCERPT)153
1.18 EXAMPLE 18. PRESCRIPTION CHANGE REQUEST FROM PHARMACY FOR AN EXISTING "FILLABLE"
PRESCRIPTION (EXCERPT)............................................................................................................... 154
1.19 EXAMPLE 19. PRESCRIBER REQUESTS MEDICATION HISTORY ................................................ 157
1.20 EXAMPLE 20. PRESCRIBER SENDS THE ORIGINAL ORDER, THEN CHANGES THE ORIGINAL ORDER,
SIGNIFICANTLY (DIRECT CONNECT) .................................................................................................. 168
1.21 EXAMPLE 21. PRESCRIBER REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE ELEMENT ... 173
1.22 EXAMPLE 22. PHARMACY REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE ELEMENT ... 174
1.23 EXAMPLE 23. SIG ELEMENT EXAMPLES.............................................................................. 180
1.23.1 Text Sig Examples .................................................................................................. 180
1.23.2 Structured Sig Examples ........................................................................................ 180
1.24 EXAMPLE 24. PHARMACY REQUESTS CURRENT MEDICATION LIST.......................................... 241
1.25 EXAMPLE 25. EXAMPLES OF NEW PRESCRIPTIONS FOR COMPOUND INGREDIENTS .................... 245
1.25.1 Prescription for: Amlodipine 1.25mg/ml Suspension............................................. 245
1.25.2 Prescription for: Progesterone 100mg SR Capsules ............................................... 250
1.25.3 Prescription for: Mupirocin/Betamethasone/Clotrimazole Ointment ................... 257
1.25.4 Prescription for: Nifedipine 0.2% Ointment ........................................................... 263
1.26 EXAMPLE 26. PRESCRIBER SUSPENDS MEDICATION ADMINISTRATION FOR A CLINICAL REASON, THEN
RESUMES (DIRECT CONNECT) ......................................................................................................... 269
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1.27 EXAMPLE 27. PHARMACY REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE ELEMENT FROM
A PRESCRIBER (DIRECT CONNECT) ................................................................................................... 282
1.28 EXAMPLE 28. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG KNOWN) FROM
PHARMACY TO PRESCRIBER (DIRECT CONNECT) ................................................................................. 287
1.29 EXAMPLE 29. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG UNKNOWN) FROM
1.30 EXAMPLE 30. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG CLASS) FROM
1.31 EXAMPLE 31. NEWRXREQUEST DENIED FOR NEW PRESCRIPTION (DRUG CLASS) FROM PHARMACY
TO PRESCRIBER (DIRECT CONNECT) ................................................................................................. 303
1.32 EXAMPLE 32. PRIOR AUTHORIZATION NOT REQUIRED ......................................................... 308
1.33 EXAMPLE 33. PRIOR AUTHORIZATION INITIATION, REQUEST AND APPROVAL ........................... 319
1.34 EXAMPLE 34. PRIOR AUTHORIZATION DENIAL AND APPEAL .................................................. 351
1.35 EXAMPLE 35. PRIOR AUTHORIZATION WITH CODED REFERENCE ............................................ 389
1.36 EXAMPLE 36. PA PROCESS CANCELATION .......................................................................... 408
1.37 EXAMPLE 37. RXTRANSFER (ALL)..................................................................................... 422
1.38 EXAMPLE 38. RXTRANSFER (ALL – MULTIPLE PRESCRIPTIONS) ............................................. 443
1.39 EXAMPLE 39. RXTRANSFER (SPECIFIC) ............................................................................ 464
1.40 EXAMPLE 40. RXTRANSFERRESPONSE WITH TWO TRANSFERS ............................................... 469
1.41 EXAMPLE 41. RXFILLINDICATORCHANGE ........................................................................... 479
1.42 EXAMPLE 42. REMS – STANDARD PRESCRIPTION DATA – NO QUESTIONS.............................. 481
1.43 EXAMPLE 43: REMS – STANDARD PRESCRIPTION DATA – NO QUESTIONS – CLOSED ....... 505
1.44 EXAMPLE 44: REMS – QUESTIONS – APPROVED ................................................................ 528
1.45 EXAMPLE 45: REMS – QUESTIONS – CLOSED .................................................................... 555
1.46 EXAMPLE 46: REMS - NEWRX (FROM PRESCRIBER) ............................................................ 582
1.47 EXAMPLE 47: REMS - PRESCRIPTION CHANGE REQUEST (VIA DIRECT CONNECT)..................... 589
2. APPENDIX B. HISTORY OF IMPLEMENTATION GUIDE CHANGES..................................... 599
2.1 VERSION 10 ..................................................................................................................... 599
2.2 VERSION 11 ..................................................................................................................... 599
2.3 VERSION 12 ..................................................................................................................... 599
2.4 VERSION 13 ..................................................................................................................... 599
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1. TRANSMISSION EXAMPLES
This document contains examples messages based on the NCPDP SCRIPT Standard Implementation Guide. Each SCRIPT Standard Examples Guide
is version dependent on the SCRIPT Standard Implementation Guide. The specified version of the SCRIPT Standard Examples Guide is applicable
only to the same version of the SCRIPT Standard Implementation Guide.
Listed below are examples of conversations between a Pharmacy, Prescriber, Entity, and Mailbox systems. In each example, the conversation
segments that make up a given transaction are shown, as well as sample data showing a conversation. Since there is latitude in the data
elements that make up a given segment, the examples are illustrative only. The codes used in the examples are those as of the date the
document was published and are subject to change.
Example Data Elements

In the examples, the following key data may be used:
Field Name Value
Clinic ID 77777777
Clinic ID Qualifier C
Clinic’s Password to Mailbox PASSWORDA
Clinic’s Password to Pharmacy 1 PASSWORDQ
Clinic’s Password to Pharmacy 2 PASSWORDAAA
Clinic’s Password to Payer PWPHY
Clinic’s Name STATE CLINIC
Clinic’s Software MDLITE, 443, 2.1
Physician’s Name MARK JONES

Physician’s State ID 6666666
Physician’s Address 211 CENTRAL ROAD, JONESVILLE, TN, 37777, US
Physician’s Telephone 6152219800
Physician’s Name TIM JONSON
Physician’s State ID 3334444
Physician’s Address 151 EAST STREET, CLYDE, ME 11122, US
Physician’s Telephone 2078659191
Mailbox ID 111111
Mailbox ID Qualifier M
Pharmacy 1 ID 7701630 (NCPDP ID)

Pharmacy 1 ID 7878787878 (NPI)
Pharmacy 1 ID Qualifier P
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Field Name Value
Pharmacy 1 Password to Mailbox PASSWORDB
Pharmacy 1 Password to Clinic PASSWORD5
Pharmacy 1 Password to Pharmacy 2 PASSWORDC
Pharmacy 1 Name MAIN STREET PHARMACY
Pharmacy 1 Address 5400 S 121 ST
HALES CORNERS, TN 37122, US
Pharmacy 1 Telephone 6152205656
Pharmacy 1 Software ACE SOFTWARE, ACE123, 1.1
Facility ID FACILITY123
Facility’s Password to Payer PASSWORDF
Payer ID PAYER123
Payer’s Password to Pharmacy PASSWORDZ
Payer’s Password to Facility PASSWORDQ
Patient 1 ID 333445555
Patient 1 Name MARY SMITH
Patient 1 Address 45 EAST ROAD SW, CLANCY, WI, 54999, US
Patient 1 Date of Birth 12/25/1954
Patient 2 ID 222222222
Patient 2 Name JEFFREY TURNER
Patient 2 Address 1991 CELVIN ROAD, JONESVILLE, TN, 37777, US
Patient 2 Date of Birth 11/29/1957

Pharmacy 2 Password to Mailbox PASSWORD2
Pharmacy 2 Password to Pharmacy 1 PASSWORD222
Pharmacy 2 Name CHENG PHARMACY
Pharmacy 2 Address 400 S AMES ST
SMITH, NJ 07001

Pharmacy 3 Password to Mailbox PASSWORD333
Pharmacy 3 Name MARK PHARMACY
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Field Name Value
Pharmacy 3 Address 1400 S JAMES ST
MARK, NJ 07022
All requests and responses have two “tie back” fields. The first is <MessageID> which relates to the transmission. The second “tie back” field is
<RelatesToMessageID> which is used to link transactions. See NCPDP XML Standard for usage rules.
Note: diagnosis codes – The codes listed are for example purposes only, and may not be exactly correct. Refer to owner’s code set rules and
formats.
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1.1 EXAMPLE 1. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY (VIA A MAILBOX)
In this example a new prescription request is sent from the prescriber to the mailbox. The pharmacy requests mail of the Mailbox and receives
the new prescription request from the mailbox. The prescriber is sending a new prescription request for Calan SR for patient Mary Smith.
Notice in the new prescription sent to the pharmacy from the Mailbox, the <Password> has been removed since the pharmacy should not see
the <Password> that was sent from the prescriber to the Mailbox. <RxFillIndicator> is used.
Transaction
NewRx (from Prescriber)
Status (from Mailbox)
GetMessage (from Pharmacy)
NewRx (From Mailbox)
Status (No More Mail, from Mailbox)
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NewRx
Status
Pharmacy System
Connects
GetMessage
Prescriber
Pharmacy
Mailbox
NewRx
GetMessage
Status (no more mail)
Pharmacy System
Disconnects
GetMessage from
NewRx from Prescriber Pharmacy GetMessage from Pharmacy
Field Name Value Value Value
<MessageID> 1234567 A22 A25
<RelatesToMessageID>
<PrescriberOrderNumber> 110088
<RxReferenceNumber>
Status from Mailbox NewRx from Mailbox Status from Mailbox (no
more mail)
<MessageID> 66666681 1234567 66666684
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<RelatesToMessageID> 1234567 A25
<RxReferenceNumber>

<?xml version="1.0" encoding="UTF-8"?>

<Message DatatypesVersion="20170714" TransportVersion="20170714" TransactionDomain="SCRIPT" TransactionVersion="20170714" StructuresVersion="20170714" ECLVersion="20170714"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="transport.xsd">
<Header>
<To Qualifier="P">7701630</To>
<From Qualifier="C">77777777</From>
<MessageID>1234567</MessageID>
<SentTime>2010-10-01T08:15:22</SentTime>
<Security>
<UsernameToken>
<Password Type="PasswordDigest">String</Password>
<Created>2001-12-17T09:30:47Z</Created>
</UsernameToken>
<Sender>
<SecondaryIdentification>PASSWORDA</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
<SenderSoftwareDeveloper>MDLITE</SenderSoftwareDeveloper>
<SenderSoftwareProduct>443</SenderSoftwareProduct>
<SenderSoftwareVersionRelease>2.1</SenderSoftwareVersionRelease>
</SenderSoftware>
<PrescriberOrderNumber>110088</PrescriberOrderNumber>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
<SocialSecurity>333445555</SocialSecurity>
</Identification>
<Name>
<LastName>SMITH</LastName>
<FirstName>MARY</FirstName>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
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</DateOfBirth>
<Address>
<AddressLine1>45 EAST ROAD SW</AddressLine1>
<City>CLANCY</City>
<StateProvince>WI</StateProvince>
<PostalCode>54999</PostalCode>
<CountryCode>US</CountryCode>
</Address>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>6512551122</Number>
</PrimaryTelephone>
</CommunicationNumbers>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NCPDPID>7701630</NCPDPID>
<NPI>7878787878</NPI>
</Identification>
<BusinessName>MAIN STREET PHARMACY</BusinessName>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
<LastName>JONES</LastName>
<FirstName>MARK</FirstName>
</Name>
<Address>
<AddressLine1>211 CENTRAL ROAD</AddressLine1>
<City>JONESVILLE</City>
<StateProvince>TN</StateProvince>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
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<MedicationPrescribed>
<DrugDescription>CALAN SR 240MG</DrugDescription>
<DrugCoded>
<Strength>
<StrengthValue>240</StrengthValue>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<StrengthUnitOfMeasure>
<Code>C28253</Code>
</StrengthUnitOfMeasure>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<CodeListQualifier>38</CodeListQualifier>
<QuantityUnitOfMeasure>
<Code>C48542</Code>
</QuantityUnitOfMeasure>
</Quantity>
<DaysSupply>30</DaysSupply>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Substitutions>0</Substitutions>
<NumberOfRefills>1</NumberOfRefills>
<Sig>
<SigText>TAKE ONE TABLET TWO TIMES A DAY UNTIL GONE</SigText>
</Sig>
<RxFillIndicator>All Fill Statuses Except Transferred</RxFillIndicator>
<PrescriberCheckedREMS>A</PrescriberCheckedREMS>
</MedicationPrescribed>
</NewRx>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This is
the destination.
From 77777777:C This is the Clinic ID of the sender; C means it is a Clinic.
MessageID 1234567 Clinic system trace number for the transmission. Echoed back in the
response transaction in RelatesToMessageID.
RelatesToMessageID Not sent. Not applicable.
SecondaryIdentification PASSWORDA The password of the Clinic to the Mailbox.
NewRx NewRx The transaction type: New Prescription.
SentTime 2010-10-01T08:15:22 Date and time transaction was sent 10/1/2010 08:15:22 AM
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Element Value Note
SenderSoftwareDeveloper, MDLITE:443:2.1 Sender Software Developer: MDLITE
SenderSoftwareProduct, Sender Software Product: 443
SenderSoftwareVersionRele Sender Software Version Release: 2.1
ase
PrescriberOrderNumber 110088 This is the reference number assigned by the prescribing system.
RxReferenceNumber Not sent. Not applicable.
SocialSecurity 333445555 Patient’s Social Security Number.
LastName, FirstName SMITH:MARY Patient’s Name: Mary Smith
Gender F Female
DateOfBirth 1954-12-25 Patient’s date of birth 12/25/1954
Address 45 EAST ROAD SW, The patient’s address.
CLANCY, WI, 54999, US
NCPDPID 7701630 NCPDP Provider ID Number of Pharmacy.
NPI 7878787878 National Provider ID of Pharmacy.
StoreName MAIN STR... Name of Pharmacy
CommunicationNumber 6152205656 Phone Number of Pharmacy (615) 220-5656.
NPI 666666666 NPI of the Prescriber
LastName, FirstName JONES:MARK The prescriber’s name: Mark Jones
Address 211 CENTRAL ROAD, The prescriber’s address.
JONESVILLE, TN, 37777,
US
CommunicationNumber 6152219800 The prescriber’s phone number (615) 221-9800.
MedicationPrescribed
DrugDescription CALAN SR 240MG Drug prescribed is Calan Sr 240mg.
Strength, 240 240 is the strength.
StrengthForm C42998 The Source for NCPDP Drug Dosage Form Terminology- C42998 is the code
for “Tablet dosing form”. So this means the prescription is for 240mg
tablets.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology. C28253
is the code for “Milligram”.
Quantity 60:38 The quantity is 60. 38 is the code value for Original Qty.
QuantityUnitOfMeasure C48542 The Source for NCPDP QuantityUnitOfMeasure Terminology- C48542 is the
code for “Tablet”.
WrittenDate 2010-10-01 Date written 10/01/2010.

DaysSupply 30 30 is the number of days supply.
Substitutions 0 0 is No Product Selection Indicated, which means substitution is allowed.
NumberOfRefills 1 One refill is allowed.
SigText TAKE ONE TABLET TWO TAKE ONE TABLET…. is the Sig.
TIMES A DAY UNTIL
GONE
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Element Value Note
RxFillIndicator ALL FILL STATUSES The prescriber’s intent to receive RxFill Status Notifications for this
EXCEPT TRANSFERRED patient/medication that are dispensed, partially dispensed and not
dispensed.

<Header>
<To Qualifier="C">77777777</To>
<From Qualifier="M">111111</From>
<RelatesToMessageID>1234567</RelatesToMessageID>
<SenderSoftware>
<SenderSoftwareDeveloper>SWITCH123</SenderSoftwareDeveloper>
<SenderSoftwareProduct>ROUTEA</SenderSoftwareProduct>
<SenderSoftwareVersionRelease>55</SenderSoftwareVersionRelease>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Per the rules, the Mailbox assigns their own trace number <MessageID> and echoes back the prescriber trace number <RelatesToMessageID>.
Element Value Note
To 77777777:C Clinic ID; C means clinic. Now the destination.
From 111111:M Mailbox ID. Now the sender.
MessageID 66666681 Mailbox trace number for this transmission.
RelatesToMessageID 1234567 Prescriber trace number is used to link the (MessageID) from
request to the response.
PrescriberOrderNumber Not sent. Not applicable.
Status Status The transaction type: Status
Status Code 000 The status type  000 means no error.
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The SentTime indicates that this transaction was sent at 8:20:23 AM on 10/01/2010
<Header>
<To Qualifier="M">111111</To>
<From Qualifier="P">7701630</From>
<MessageID>A22</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
<SecondaryIdentification>PASSWORDB</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
<SenderSoftwareDeveloper>ACE SOFTWARE</SenderSoftwareDeveloper>
<SenderSoftwareProduct>ACE123</SenderSoftwareProduct>
</SenderSoftware>
</Header>
<Body>
<GetMessage></GetMessage>
</Body>
</Message>
Notes:
Element Value Note
MessageID A22 Pharmacy trace number for the transmission.
SecondaryIdentification PASSWORDB The current password.
GetMessage GetMessage The transaction type: Get Message
SenderSoftwareDeveloper, ACE Sender Software Developer: ACE SOFTWARE
SenderSoftwareProduct SOFTWARE:ACE1:1.1 Sender Software Product: ACE1
and Sender Software Version Release: 1.1
SenderSoftwareVersionRel
ease
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NewRx (from Mailbox)
There is a piece of mail waiting for the pharmacy. The Mailbox responds to the GetMessage request with the NewRx. See above Notes that
describe the actual fields in the NewRx.
<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
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</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
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</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</NewRx>
</Body>
</Message>
Notes:
Per the rules, the Mailbox has mail to deliver and does not assign their own trace number. The Mailbox delivers what the NewRx contained when the Mailbox
received the transaction. Note Security and Password information from the prescriber are not sent forward.
Element Value Note
To 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This is the
destination.
MessageID 1234567 Clinic system trace number for this transmission that the Mailbox
accepted in the NewRx.
RelatesToMessageID Not used. Not applicable in Mailbox scenario.
SentTime 2010-10- Date and time transaction was sent 10/01/2010 08:15:22 AM
01T08:15:22
SenderSoftwareVersionRelea Sender Software Version Release: 2.1
se
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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>
Notes:
Element Value Note
MessageID A25 Pharmacy trace number for the transmission. Echoed back in the response
transaction in RelatesToMessageID.
GetMessage GetMessage The transaction type: GetMessage
SenderSoftwareProduct, SOFTWARE:A Sender Software Product: ACE1
SenderSoftwareVersionRel CE1:1.1 Sender Software Version Release: 1.1
ease
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xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="transport.xsd"> <Header>
<RelatesToMessageID>A25</RelatesToMessageID>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>002</Code>
</Status>
</Body>
</Message>
Notes:
Per the rules, the Mailbox assigns their own trace number <MessageID> and echoes back the pharmacy trace number <RelatesToMessageID>.
Element Value Note
destination.
RelatesToMessageID A25 Pharmacy trace number is used to link the Status to the GetMessage.
Status Code 002 The status type  002 means no more mail
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1.2 EXAMPLE 2. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY (DIRECT CONNECT)
In this example a new prescription request is sent directly from the prescriber to the pharmacy. It is assumed that there is a direct connection
(dedicated line) between the prescriber (clinic) and pharmacy. This example uses the same data as Example 1, with the addition of limited
known allergy and/or adverse event information.
In a direct connect scenario, the trading partners must agree on passwords between the two systems.
Transaction
Status (from Pharmacy)
NewRx
Prescriber
Pharmacy
Status
NewRx from Prescriber

Field Name Value
<MessageID> 1234567
<RxReferenceNumber>
Status from Pharmacy
<MessageID> ABC11
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<RelatesToMessageID> 1234567
<PrescriberOrderNumber>
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
<SecondaryIdentification>PASSWORDQ</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<AllergyOrAdverseEvent>
<Allergies>
<SourceOfInformation>C</SourceOfInformation>
<AdverseEvent>
<Text>Propensity to adverse reactions to substance</Text>
<Code>418038007</Code>
</AdverseEvent>
<DrugProductCoded>
<Text>Latex</Text>
</DrugProductCoded>
</Allergies>
</AllergyOrAdverseEvent>
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22
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
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23
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</NewRx>
</Body>
</Message>
Notes:
See detailed elements in example 1 above.
V13
24
Element Value Note
To 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This
is the destination. It must be the pharmacy ID.
response transaction in the RelatesToMessageID.
SecondaryIdentification PASSWORDQ Password of the Clinic directly to the Pharmacy, if used, depending on
trading partner agreements.
ase
AllergyOrAdverseEvent
SourceOfInformation C Indicates information is provided by a clinician or provider
AdverseEvent Propensity to adverse Used to record an adverse reaction to an environmental agent.
reactions to
substance :418038007
DrugProductCoded Latex
dispensed.

<Header>
<MessageID>ABC11</MessageID>
<SenderSoftware>
</SenderSoftware>
V13
25
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
From 7701630:P Pharmacy ID. Now the sender.
MessageID ABC11 Pharmacy trace number for this transmission.
RelatesToMessageID 1234567 Prescriber trace number is used to link the (MessageID) from request to the
response.
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26
1.3 EXAMPLE 3. PRESCRIBER SENDING A NEW PRESCRIPTION TO A PHARMACY WITH A RETURN RECEIPT
REQUESTED
In this example a new prescription request is sent from the prescriber to the Mailbox. The pharmacy issues a GetMessage to the Mailbox to pick
up mail. The Mailbox responds with the NewRx. The new prescription includes a request for a return receipt. It is the responsibility of the
pharmacy system to send the Verify. This can be performed either in a separate call to the Mailbox or as part of the call sending the NewRx
transaction. The appropriate choice will depend on the architecture of the pharmacy system. In this example, the pharmacy sends the Verify as
a standalone transaction.
This example uses the same data as Example 1 - a prescription for CALAN SR 240mg for patient Mary Smith.
It is possible that the pharmacy system can be retrieving mail transactions and at the same time, review transactions for return receipt. Before
the pharmacy system has disconnected from the Mailbox, the system could generate the Verify in the same session.
Transaction
NewRx with ReturnReceipt request (from
Prescriber)
…
NewRx with ReturnReceipt request (from
Mailbox)
...
Verify for NewRx (from Pharmacy)
…
GetMessage (from Prescriber)
Verify for NewRx (from Mailbox)
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27
Prescriber System Connects
NewRx
Status
Pharmacy System
Connects
Prescriber System
Disconnects GetMessage
NewRx
GetMessage
Pharmacy System
Disconnects
Prescriber
Pharmacy
Pharmacy System
Mailbox
Connects
Verify
Status
Pharmacy System
Disconnects
Prescriber System Connects
GetMessage
Verify
GetMessage
Prescriber System
Disconnects
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28
NewRx with GetMessage from GetMessage from Pharmacy Verify for NewRx from GetMessage from Prescriber GetMessage from Prescriber
ReturnReceipt request Pharmacy Pharmacy
from Prescriber
Field Name Value Value Value Value Value Value
<MessageID> 1234567 A22 A25 A30 1234 1237
<PrescriberOrderNumber> 110088 110088
<RxReferenceNumber>
Status from Mailbox NewRx with Status from Mailbox (no Status from Mailbox Verify for NewRx from Status from Mailbox (no
ReturnReceipt request more mail) Mailbox more mail)
from Prescriber from
Mailbox
<MessageID> 66666681 1234567 66666684 66666685 A30 66666687
<RelatesToMessageID> 1234567 A25 A30 1234567 1237
<RxReferenceNumber>
NewRx with ReturnReceipt request (from Prescriber)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
V13
29
</Header>
<Body>
<NewRx>
<ReturnReceipt>1</ReturnReceipt>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
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30
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</NewRx>
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31
</Body>
</Message>
Notes:
Element Value Note
the destination. It must be the pharmacy ID.
SecondaryIdentification PASSWORDA Password of the Clinic to the Mailbox.
ase
ReturnReceipt 1 1 means that return receipt is being requested. Anything else means it is not.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
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32
</Status>
</Body>
</Message>
Notes:
Element Value Note
response.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
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33
</Body>
</Message>
NewRx (from Mailbox)
There is a piece of mail waiting for the pharmacy. The Mailbox responds to the GetMessage request with the NewRx. See above Notes that
describe the actual fields in the NewRx.
<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<ReturnReceipt>1</ReturnReceipt>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
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34
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
V13
35
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</NewRx>
</Body>
</Message>
Notes:
Per the rules, the Mailbox has mail to deliver and does not assign their own trace number. The Mailbox delivers what the NewRx contained when the Mailbox
received the transaction.
Element Value Note
destination.
MessageID 1234567 Clinic system trace number for this transmission that the Mailbox accepted in
the NewRx.
RelatesToMessageID Not used. Not applicable in Mailbox scenario.
01T08:15:22

V13
36
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>
Notes:
Element Value Note
MessageID A25 Pharmacy trace number for the transmission. Echoed back in the response
GetMessage GetMessage The transaction type: GetMessage

<Header>
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37
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>002</Code>
</Status>
</Body>
</Message>Notes:
Element Value Note
destination.
RelatesToMessageID A25 Pharmacy trace number is used to link the Status to the GetMessage.
Status Code 002 The status type  002 means no mail.
The pharmacy system then generates the Verify.
Verify for NewRx (from Pharmacy)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
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38
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Verify></Verify>
</Body>
</Message>
Notes:
Element Value Note
To 77777777: This is the Clinic ID; C means it is a Clinic. This is the receiver.
C
From 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This is the sender.
MessageID A30 Pharmacy system trace number for the transmission. Echoed back in the response
RelatesToMessageID 1234567 This is the reference number assigned by the prescribing system in the NewRx. Used
to link the (MessageID) from request to the response or subsequent follow up
transaction.

Verify Verify Verify transaction, generated to acknowledge the return receipt requested in the
original transaction.
Status to Verify (from Mailbox)

<Header>
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39
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P Pharmacy ID; P means pharmacy. Now the destination.
RelatesToMessageID A30 Pharmacy trace number is used to link the (MessageID) from request to the
response.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
V13
40
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>
Verify for NewRx (from Mailbox)

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Verify></Verify>
</Body>
</Message>
Notes:
Per the rules for trace numbers, the Mailbox has mail to deliver and does not assign their own trace number. The Mailbox delivers what the Verify contained
when the Mailbox received the transaction.
Element Value Note
MessageID A30 Pharmacy system trace number for this transmission that the Mailbox accepted in the
Verify.
RelatesToMessageID 1234567 This is the reference number assigned by the prescribing system in the NewRx. Used to
link the (MessageID) from request to the response or subsequent follow up transaction.
V13
41
Element Value Note

Verify Verify Verify transaction, generated to acknowledge the return receipt requested in the original
transaction.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>Status (No More Mail, from Mailbox)
<Header>
<SenderSoftware>
V13
42
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>002</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID 1237 Prescriber trace number is used to link the Status to the GetMessage.
Status Code 002 The status type  002m means no more mail
V13
43
1.4 EXAMPLE 4. PRESCRIPTION CHANGE TRANSACTION (VIA MAILBOX)
In this example, the pharmacy in requesting permission to change the original (new) prescription. The pharmacy is requesting to substitute
generic from branded. The new prescription specified PCE but did not specify if generic could be substituted.
The pharmacy sends the RxChangeRequest to the Mailbox. The prescriber picks up the RxChangeRequest when mail is requested. Later, the
prescriber responds with the prescription change response, whether the pharmacy can substitute or not. The RxChangeResponse is then picked
up by the pharmacy, when mail is next requested from the Mailbox.
Transaction
RxChangeRequest (from Pharmacy)
...
RxChangeRequest (from Mailbox)
Status (No More Mail from Mailbox)
…
RxChangeResponse (from Prescriber)
…
RxChangeResponse (from Mailbox)
V13
44
Pharmacy System
Connects
RxChangeRequest
Status
Pharmacy System
Disconnects
Prescriber System
Connects
GetMessage
RxChangeRequest
GetMessage
Prescriber System
Pharmacy
Prescriber
Mailbox
Disconnects
After time elapse,

Prescriber System
Connects
RxChangeResponse
Status
Pharmacy System Prescriber System

Connects Disconnects
GetMessage
RxChangeResponse
GetMessage
Pharmacy System
Disconnects
V13
45
RxChangeRequest from GetMessage from GetMessage from Prescriber RxChangeResponse from GetMessage from Pharmacy GetMessage from Pharmacy
Pharmacy Prescriber Prescriber
<MessageID> A55 1234 1235 2291 A22 A63
<RxReferenceNumber> PH888 PH888
Status from Mailbox RxChangeRequest from Status from Mailbox (no Status from Mailbox RxChangeResponse from Status from Mailbox (no
Pharmacy from Mailbox more mail) Prescriber from Mailbox more mail)
<MessageID> 66666691 A55 66666693 66666694 2291 66666697
<RelatesToMessageID> A55 1234567 1235 2291 A55 A63
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 1234567 which the Mailbox retained.
The reference number <PrescriberOrderNumber>assigned by the prescribing system when they sent the NewRx was 110088.
The pharmacy has assigned prescription number <RxReferenceNumber> PH888 on their system.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
V13
46
<SenderSoftware>
</SenderSoftware>
<RxReferenceNumber>PH888</RxReferenceNumber>
</Header>
<Body>
<RxChangeRequest>
<MessageRequestCode>G</MessageRequestCode>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
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47
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Note>SUBSTITUTE GENERIC?</Note>
<Sig>
V13
48
</Sig>
</RxChangeRequest>
</Body>
</Message>
Notes:
Element Value Note
To 77777777:C This is the Clinic ID of the receiver; C means it is a Clinic.
From 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This is
the sender. It must be the pharmacy ID.
MessageID A55 Pharmacy system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234567 Prescriber trace number is used to link the original transaction (NewRx)
(MessageID) to this subsequent transaction.
SecondaryIdentification PASSWORDB This is the password of the pharmacy.
RxChangeRequest RxChangeRequest Prescription Change Request.
SentTime 2010-10- Date and time transaction was sent 10/01/2010 09:15:22 A.M.
01T09:15:22
SenderSoftwareProduct, SOFTWARE:ACE1:1.1 Sender Software Product: ACE1
se
RxReferenceNumber PH888 This is the prescription number assigned by the pharmacy system.
MessageRequestCode G Generic substitution is being requested.
Gender F Female
Address 211 CENTRAL The prescriber’s address.
ROAD:JONESVILLE:T
N:37777
DrugDescription PCE 333 MG PCE 333 mg is the prescribed drug.
Strength 333 333 is the strength
V13
49
Element Value Note
StrengthForm C42998 The Source for NCPDP Drug StrengthForm Terminology- C42998 is the code
for “Tablet dosing form”. So this means the prescription is for 333 mg tablets.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology. C28253 is
the code for “Milligram”.
WrittenDate 2010-10-01 Date Written 10/01/2010.

Substitutions 1 Dispense as Written 1 = Substitution not allowed by prescriber.
NumberOfRefills 0 No refills are allowed.
Note SUBSTITUTE Pharmacy is asking to substitute generic for PCE.
GENERIC?
SigText TAKE ONE TABLET…. TAKE ONE TABLET… is the Sig.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
V13
50
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>
RxChangeRequest (from Mailbox)

<Header>
<SenderSoftware>
</SenderSoftware>
V13
51
</Header>
<Body>
<RxChangeRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
V13
52
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</RxChangeRequest>
</Body>
</Message>
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53
Notes:
Per the rules, the Mailbox has mail to deliver and does not assign their own trace number. The Mailbox delivers what the RxChangeRequest contained when
the Mailbox received the transaction.
Element Value Note
(MessageID).

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
</Body>
</Message>
V13
54
<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>002</Code>
</Status>
</Body>
</Message>
Notes:

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
V13
55
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved/>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
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56
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
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57
</WrittenDate>
<Sig>
</Sig>
</RxChangeResponse>
</Body>
</Message>
Notes:
See above for details.
Element Value Note
the receiver. It must be the pharmacy ID.
MessageID 2291 Prescriber system trace number for the transmission. Echoed back in the
RelatesToMessageID A55 Pharmacy trace number is used to link the original transaction (MessageID)
from the RxChangeRequest.
SentTime 2010-10- Date and time transaction was sent 10/01/2010 at 09:24:36 A.M.
01T09:24:36
SecondaryIdentification PASSWORDA This is the password for the Clinic.
SenderSoftwareVersionReleas Sender Software Version Release: 2.1
e
Must be the same value as in UIT Message Reference Number.
RxChangeResponse RxChangeResponse Prescription Change Response.
Approved Approved The request for substitution was approved by the prescriber.

<Header>
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58
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Per the rules, the Mailbox assigns their own trace number <MessageID> and echoes back the prescriber’s trace number <RelatesToMessageID>.
This mail request occurred at 12:15:30. The delay in the response is based primarily, on the delay associated with getting the prescriber to approve the
change.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
V13
59
</SenderSoftware>
</Header>
<Body>
<GetMessage/>
</Body>
</Message>
RxChangeResponse (from Mailbox)

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved/>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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60
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
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61
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</RxChangeResponse>
</Body>
</Message>
Notes:
Per the rules for trace numbers, the Mailbox has mail to deliver and does not assign their own trace number. The Mailbox delivers what the RxChangeResponse
contained when the Mailbox received the transaction.

<Message DatatypesVersion=“20170714” TransportVersion=“20170714” TransactionDomain=“SCRIPT” TransactionVersion=“20170714” StructuresVersion=“20170714” ECLVersion=“20170714”
xmlns:xsi=“http://www.w3.org/2001/XMLSchema-instance” xsi:noNamespaceSchemaLocation="transport.xsd">
<Header>
<Security>
<UsernameToken>
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62
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<GetMessage/>
</Body>
</Message>

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>002</Code>
</Status>
</Body>
</Message>
Notes:
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63
1.5 EXAMPLE 5. PRESCRIPTION CHANGE REQUEST (VIA DIRECT CONNECT)
In this example, the pharmacy is requesting permission to change the original (new) prescription. The pharmacy is requesting to substitute
generic from brand. In this scenario the pharmacy and prescriber are directly connected (e.g. via dedicated line). Since the prescriber will
probably not be able to answer the change request real-time, the change response will come back to the pharmacy sometime in the future. This
example uses the same data as Example 6, but also includes the <RxFillIndicator>.
Transaction
Status (from Prescriber)
...
RxChangeRequest
Status
Prescriber
Pharmacy
After elapsed time
RxChangeResponse
Status
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RxChangeRequest from RxChangeResponse from
Pharmacy Prescriber
Field Name Value Value
<MessageID> A55 2291
Status from Prescriber Status from Pharmacy
<MessageID> 22222 8888

<RelatesToMessageID> A55 2291
<RxReferenceNumber>
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 1234567 (from Example 2).
The reference number <PrescriberOrderNumber> assigned by the prescribing system when they sent the NewRx was 110088.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
<SecondaryIdentification>PASSWORD5</SecondaryIdentification>
</Sender>
</Security>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
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<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
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</Sig>
</RxChangeRequest>
</Body>
</Message>
Notes:
See detail in previous example.
Element Value Note
SecondaryIdentification PASSWORD5 This is the password of the pharmacy on the prescriber's system.
SentTime 2010-10-01T09:15:22 Date and time transaction was sent 10/01/2010 09:15:22 A.M.
ase
GENERIC?

<Header>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
MessageID 22222 Prescriber trace number for this transmission.
RelatesToMessageID A55 Pharmacy trace number is to link the (MessageID) from request to the response.
The prescriber systems sends an answer to the RxChangeRequest.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved/>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
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<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
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</Sig>
</RxChangeResponse>
</Body>
</Message>
Notes:
See detail above.
Element Value Note
receiver. It must be the pharmacy ID.
RelatesToMessageID A55 Pharmacy trace number is used to link the original transaction
(RxChangeRequest) (MessageID) to this subsequent transaction.
01T09:24:36
SecondaryIdentification PASSWORDQ This is the password for the Clinic.
se
RxChangeResponse RxChangeRespon Prescription Change Response.
se
Approved Approved The request for substitution was approved by the prescriber.
RxFillIndicator ALL FILL The prescriber’s intent to receive RxFill Status Notifications for this
STATUSES patient/medication for all fill statuses except transferred.
EXCEPT
TRANSFERRED

<Header>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
MessageID 8888 Pharmacy trace number for this transmission.
RelatesToMessageID 2291 Prescriber trace number is used to link the (MessageID) from request to the response.
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1.6 EXAMPLE 6. PHARMACY REQUESTING A RENEWAL AUTHORIZATION FOR 4 ADDITIONAL DISPENSINGS
FROM A PRESCRIBER AND PRESCRIBER RESPONDING
In this example, the Pharmacy is requesting permission for a renewal for Theo-Dur for patient Jeffrey Turner. In this example, the pharmacy is
requesting a specific number of refills, so <PharmacyRequestedRefills> is sent in the RxRenewalRequest.
In the RxRenewalResponse, the prescriber wishes to authorize one more dispensing, so <NumberOfRefills> contains 1. The prescriber has also
included a note asking to have the patient call for an appointment. The prescriber also changes the <RxFillIndicator>.
The Prescriber has <ApprovedWithChanges>. (When the pharmacy requests a particular number of refills, it is a change when the prescriber
approves a specific number of dispensings.)
It is the pharmacy’s choice, based on applicable regulations and legislation, and its own operating practices, whether the pharmacy implements
the additional dispensing as an additional refill on the existing prescription, or as a new prescription with an original dispensing and no
authorized refills.
Note: The <WrittenDate> on the RxRenewalResponse should not be echoed back from the request.
See also other examples.
Transaction
RxRenewalRequest (from Pharmacy)
...
RxRenewalResponse (from Prescriber)
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RxRenewalRequest
Status
Prescriber
Pharmacy
RxRenewalResponse
Status
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 2222.
RxRenewalRequest from RxRenewalResponse
Pharmacy from Prescriber

<RxReferenceNumber>
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75
<Message DatatypesVersion=“20170714” TransportVersion="20170714" TransactionDomain="SCRIPT" TransactionVersion="20170714" StructuresVersion="20170714" ECLVersion="20170714"
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxRenewalRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
<LastName>TURNER</LastName>
<FirstName>JEFFREY</FirstName>
</Name>
<Gender>M</Gender>
<DateOfBirth>
<Date>1957-11-29</Date>
</DateOfBirth>
</HumanPatient>
</Patient>
<Pharmacy>
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<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
<AddressLine1>5400 S 121 ST</AddressLine1>
<City>HALES CORNERS</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<MedicationDispensed>
<DrugDescription>THEO DUR 300MG</DrugDescription>
<DrugCoded>
<ProductCode>
<Code>00085058410</Code>
<Qualifier>ND</Qualifier>
</ProductCode>
<Strength>
<StrengthForm>
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<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<LastFillDate>
<Date>2010-10-01</Date>
</LastFillDate>
<Sig>
</Sig>
<PharmacyRequestedRefills>4</PharmacyRequestedRefills>
</MedicationDispensed>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-08-01</Date>
</WrittenDate>
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<Sig>
</Sig>
</RxRenewalRequest>
</Body>
</Message>
Notes:
Element Value Note
010T9:15:22
SecondaryIdentification PASSWORD5 This is the password of the pharmacy.
ase
RxRenewalRequest RxRenewalRequest The transaction type: RxRenewalRequest.
LastName, FirstName TURNER:JEFFREY Patient’s Name: Jeffrey Turner
Gender M Male
Pharmacy 7701630 NCPDP Provider ID Number of Pharmacy.
Address 5400 S 121 ST Address of Pharmacy
HALES CORNERS, TN
37122, US
ROAD:JONESVILLE:T
N:37777
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Element Value Note
MedicationDispensed
DrugDescription THEO DUR 300MG Dispensed drug is Theo-Dur.
ProductCode/Code and 00085058410:ND NDC number of the drug and qualifier of ND = NDC number.
Qualifier
Strength 300 300 is the drug strength
for “Tablet dosing form”.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology - C28253 is
Quantity 10:40 The quantity is 10. 40 is the qualifier for remaining quantities.
LastFillDate 2010-10-01 10/01/2010 is the date last filled.
PharmacyRequestedRefills 4 The pharmacy is requesting 4 additional refills.
DrugDescription THEO DUR 300MG THEO DUR is the drug prescribed.
WrittenDate 2010-08-01 Date Written 08/ 01/2010.

NumberOfRefills 2 Two refills are allowed.
SigText TAKE ONE TABLET TAKE ONE TABLET…. is the Sig.
TWO TIMES A DAY
UNTIL GONE

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<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
The prescriber system responds to the RxRenewalRequest.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
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<Body>
<RxRenewalResponse>
<Response>
<ApprovedWithChanges>
<Note>ONE REFILL AUTH. HAVE PATIENT MAKE APPT</Note>
</ApprovedWithChanges>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>M</Gender>
<DateOfBirth>
<Date>1957-11-29</Date>
</DateOfBirth>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
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<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<MedicationResponse>
<DrugCoded>
<ProductCode>
<Code>00085058410</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<LastFillDate>
<Date>2010-08-01</Date>
</LastFillDate>
<Sig>
</Sig>
<RxFillIndicator>Not Dispensed</RxFillIndicator>
</MedicationResponse>
</RxRenewalResponse>
</Body>
</Message>
Notes:
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See above for more details.
Element Value Note
(RxRenewalRequest) (MessageID) to this subsequent transaction.
RxRenewalResponse RxRenewalResponse The transaction type: RxRenewalResponse.
ApprovedWithChanges ApprovedWithChang ApprovedWithChanges since the <PharmacyRequestedRefills> was sent on
es the RxRenewalRequest and the <NumberOfRefills> on the
RxRenewalResponse is different.
Note ONE REFILL… Text. Patient is to make an appointment with the prescriber.
MedicationResponse
DrugDescription THEO DUR 300 MG THEO DUR is the drug prescribed.
ProductCode/Code and 00085058410:ND NDC number of the drug and qualifier of ND = NDC number.
Qualifier
WrittenDate 2010-10-01 Date Written 10/01/2010. WrittenDate on the RxRenewalResponse should

not be echoed back from the RxRenewalRequest.
LastFillDate 2010-08-01 08/01/2010 is the date last filled.
TWO TIMES A DAY
UNTIL GONE
RxFillIndicator NOT DISPENSED The prescriber’s intent to receive RxFill Status Notifications for this
patient/medication only if not dispensed.

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<Header>
<SenderSoftware>
<SenderSoftwareProduct>ACE</SenderSoftwareProduct>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.7 EXAMPLE 7. RENEWAL PRESCRIPTION TRANSACTION WITH RETURN RECEIPT REQUESTED

In this example, the flow is similar to example 6. However, a return receipt is requested on the RxRenewalRequest, and therefore a Verify
transaction is generated in response. Return receipt is similar to certified mail at the post office  the sender wishes to be notified when the
transaction has been accepted in the receiver’s system. The prescriber system send a Verify transaction.
Subsequently, the clinic sends a RxRenewalResponse to the pharmacy with the doctor’s approval or denial of the RxRenewalRequest. The
RxRenewalResponse requests ReturnReceipt. The pharmacy system generates a Verify transaction.
The <WrittenDate> on the RxRenewalResponse should not be echoed back from the request.
Transaction
...
Verify (from Prescriber)
…
…
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Transaction
Verify (from Pharmacy)
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RxRenewalRequest with
ReturnReceipt set
Status
Verify
Status
Prescriber
Pharmacy
RxRenewalResponse with
ReturnReceipt set
Status
Verify
Status
RxRenewalRequest from Verify from Prescriber RxRenewalResponse from Verify from Pharmacy
Pharmacy Prescriber
Field Name Value Value Value Value
<MessageID> A22 3103 2290 7772
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<RelatesToMessageID> 2222 A22 A22 2290
<PrescriberOrderNumber> 4444444 4444444 4444499
<RxReferenceNumber> PH111 PH111 PH111
Status from Prescriber Status from Pharmacy Status from Pharmacy Status from Prescriber
<MessageID> 8888 7771 6668 3104

<RelatesToMessageID> A22 3103 2290 7772
<RxReferenceNumber>
This is the same as example 6 except the RxRenewalRequest and the RxRenewalResponse both set the ReturnReceipt element with 1, and the addition of the
two Verify transactions.
Notes:
Element Value Note
Verify (from Prescriber)

<Header>
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<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Verify/>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P Identification number of the Pharmacy. P is the qualifier for Pharmacy.
From 77777777:C Identification number of the Clinic. C is the qualifier for Clinic.
(RxRenewalRequest) (MessageID) to this subsequent transaction.
SecondaryIdentification PASSWORDA Password for the Clinic.
Verify Verify A Verify transaction.
SentTime 2010-10-01:09:15:26 Date and time that transaction was sent.
ase

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<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
Verify (from Pharmacy)

<Header>
<Security>
<UsernameToken>
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</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Verify/>
</Body>
</Message>

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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1.8 EXAMPLE 8. RENEWAL PRESCRIPTION TRANSACTION - PATIENT NO LONGER UNDER PRESCRIBER’S CARE
In this example, the prescriber’s response to the pharmacy might be that the patient is no longer under the prescriber’s care. Please refer to
Example 6 for the flow. The only difference is the Response. The entire conversation is not shown here, referring to Example 6. However the
RxRenewalResponse with denial is shown below.
Transaction
RxRenewalRequest from RxRenewalResponse from

Pharmacy Prescriber

<RxReferenceNumber>
Notes:
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See previous example for details.
Element Value Note
From 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This is the
sender. It must be the pharmacy ID.
01T09:15:22
SecondaryIdentification PASSWORD5 This is the password of the pharmacy.
SenderSoftwareProduct, SOFTWARE:ACE1:1. Sender Software Product: ACE1
SenderSoftwareVersionRel 1 Sender Software Version Release: 1.1
ease
RxRenewalRequest RxRenewalRequest The transaction type: RxRenewalRequest.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<RxRenewalResponse>
<Response>
<Denied>
<ReasonCode>AC</ReasonCode>
</Denied>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>M</Gender>
<DateOfBirth>
<Date>1957-11-29</Date>
</DateOfBirth>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
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<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<MedicationResponse>
<DrugCoded>
<ProductCode>
<Code>00085058410</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<LastFillDate>
<Date>2010-08-01</Date>
</LastFillDate>
<Sig>
</Sig>
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</MedicationResponse>
</RxRenewalResponse>
</Body>
</Message>
Notes:
Element Value Note
Denied Denied The request was denied. An explanation may or may not be supplied.
ReasonCode AC AC is a reason for denial code meaning that the patient is no longer under the prescriber’s
care.

<Header>
<SenderSoftware>
<SenderSoftwareProduct>ACE</SenderSoftwareProduct>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.9 EXAMPLE 9. NEW PRESCRIPTION WHICH IS A FREE/DISCOUNTED SAMPLE

In this example a new prescription request is sent to the pharmacy from a prescriber. The prescription is for a free or discounted sample that the
pharmacy is asked to dispense on behalf of a sponsoring pharmaceutical company. The conversation and the syntax is the same as in Example 2.
The only addition is the designation that the prescription is a sample in the MedicationPrescribed <PriorAuthorization>.
Transaction
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Transaction
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 1234567 which the Mailbox retained.
Notes:
Element Value Note
PriorAuthorizationID 22000123456 22000123456 is the Sample RX.
PromotionNumber
1.10 EXAMPLE 10. PRESCRIPTION CHANGE TRANSACTION FOR THERAPEUTIC INTERACTION (VIA DIRECT
CONNECT)
In this example, the pharmacy requests the therapeutic interchange/substitution of Ventolin for Proventil due to preferred product choice. The
pharmacy and prescriber are directly connected.
The <WrittenDate> on the RxChangeResponse should not be echoed back from the request.
Transaction
...
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RxChangeRequest
Status
Prescriber
Pharmacy
(after time elapse)
RxChangeResponse
Status

Pharmacy Prescriber
<RelatesToMessageID> 123466 6699
<MessageID> 66666691 8888

<RxReferenceNumber>

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeRequest>
<MessageRequestCode>T</MessageRequestCode>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
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</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>ALBUTEROL (PROVENTIL HFA) 108 (90 BASE) MCG/ACT INHALER</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42970</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
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</DrugCoded>
<Quantity>
<Value>6.7</Value>
<Code>C48155</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>TAKE 2 PUFFS EVERY 4-6 HOURS AS NEEDED</SigText>
</Sig>
<MedicationRequested>
<DrugDescription>ALBUTEROL SULFATE (VENTOLIN HFA) 108 (90 BASE) MCG/ACT IN AERS</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42960</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>6.7</Value>
<Code>C48155</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</MedicationRequested>
</RxChangeRequest>
</Body>
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</Message>
Notes:
Element Value Note
MessageID 6699 Pharmacy system trace number for the transmission. Echoed back in the
RelatesToMessageID 123466 Prescriber trace number is used to link the original message (NewRx)
RxChangeRequest RxChangeRequest The transaction type: Prescription Change Request.
SenderSoftwareVersionRel Sender Software Version Release: 1.1
ease
RxReferenceNumber PH333 This is the prescription number assigned by the pharmacy system..
MessageRequestCode T Therapeutic interchange/substitution is being requested.
Gender F Female
CommunicationNumber 6512551122 Phone Number of Pharmacy (651) 255-1122
ROAD:JONESVILLE:T
N:37777
DrugDescription ALBUTEROL This is the prescribed drug.
(PROVENTIL HFA)
108 (90 BASE)
MCG/ACT INHALER
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Element Value Note
for “Aerosol, Metered”.
StrengthUnitOfMeasure C48152 The Source for NCPDP Drug Strength Terminology – C48152 is the code for
“Microgram.
Quantity 6.7:38 The quantity is 6.7. 38 is the code value for Original Qty.
QuantityUnitOfMeasure C48155 The Source for NCPDP Drug Unit of Measure Terminology – C48155 is the
code for “Grams”.
DaysSupply 30
NumberOfRefills 5 Five refills are allowed.
SigText TAKE 2 PUFFS…. TAKE TWO PUFFS… is the Sig.
MedicationRequested
DrugDescription ALBUTEROL SULFATE Pharmacy is asking to therapeutically substitute Ventolin.
(VENTOLIN HFA) 108
(90 BASE) MCG/ACT
IN AERS
StrengthUnitOfMeasure C48152 The Source for NCPDP Drug Strength Terminology. – C48152 is the code for
“Microgram.
code for “Grams”.


<Header>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved/>
</Response>
<Patient>
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104
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
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105
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>ALBUTEROL SULFATE (VENTOLIN HFA) 108 (90 BASE) MCG/ACT IN AERS</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42960</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>6.7</Value>
<Code>C48155</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</RxChangeResponse>
</Body>
</Message>
Notes:
Element Value Note
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106
Element Value Note
RelatesToMessageID 6699 Pharmacy trace number is used to link the original transaction
SentTime 2010-10-01T09:24:36 Date and time transaction was sent 10/01/2010 at 09:24:36 A.M.
RxChangeResponse RxChangeResponse Prescription Change Response.
ease
RxReferenceNumber PH333 This is the prescription number assigned by the pharmacy system..
Approved Approved The request for therapeutic interchange/substitution was approved by the
prescriber.
Gender F Female
CommunicationNumber 6512551122 Phone Number of Pharmacy (651) 255-1122
ROAD:JONESVILLE:T
N:37777
DrugDescription ALBUTEROL This is the prescribed drug.
(PROVENTIL HFA)
108 (90 BASE)
MCG/ACT INHALER
StrengthUnitOfMeasure C48152 The Source for NCPDP Drug Strength Terminology – C48152 is the code for
“Microgram.
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Element Value Note
code for “canister”.
WrittenDate 2010-10-01 Date Written 10/01/2010. WrittenDate to not echo the WrittenDate from
RxChangeRequest.
Substitutions 0 Dispense as written – no product selection indicated.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.11 EXAMPLE 11. INFORM PRESCRIBER A PRESCRIPTION HAS BEEN DISPENSED (VIA DIRECT CONNECT)
In this example a prescription has been dispensed by the pharmacist and a notification transaction RxFill <FillStatus><Dispensed> is sent to the
prescribing physician from the pharmacy. It is assumed that there is a direct connection (dedicated line) between the prescriber (clinic) and
pharmacy.
In the direct connect scenario, the trading partners must agree on passwords between the two systems.
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Transaction
RxFill - dispensed (from Pharmacy)
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109
RxFill
Prescriber
Pharmacy
Status
NewRx from Prescriber RxFill from Pharmacy

<MessageID> 1234567 A66
<RxReferenceNumber> PH888
Status from Pharmacy Status from Prescriber

<RxReferenceNumber>
RxFill - dispensed (from Pharmacy)

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110
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxFill>
<FillStatus>
<Dispensed>
<Note>PICKED UP THIS MORNING</Note>
</Dispensed>
</FillStatus>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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111
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
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<DrugDescription>PCE 333 MG</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>TAKE ONE TABLET THREE TIMES A DAY UNTIL GONE</SigText>
</Sig>
</RxFill>
</Body>
</Message>
Notes:
Element Value Note
SecondaryIdentification PASSWORDQ This is the password of the pharmacy.
RxFill RxFill The transaction type: Prescription Fill Status Notification.
SentTime 2010-11T09:15:22 Date and time transaction was sent 11/01/2010 09:15:22 A.M.
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Element Value Note
ase
Dispensed Dispensed Denoting prescription has been dispensed
Note PICKED UP THIS Explanation about pickup.
MORNING
Address
Gender F Female
ROAD:JONESVILLE:T
N:37777
MedicationDispensed
DrugDescription PCE 333 MG PCE 333 mg is the dispensed drug.
for “Tablet dosing form”. So this means the prescription is for 333 mg
tablets.
Quantity 30:87 The quantity is 30. 87 is the code value for Quantity Received.

Substitutions 0 Dispense as written. No product selection indicated.
SigText TAKE ONE TABLET…. TAKE ONE TABLET… is the Sig.
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<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.12 EXAMPLE 12. INFORM PRESCRIBER A PRESCRIPTION HAS NOT BEEN DISPENSED AND WILL BE RETURNED
TO STOCK
In this example a prescription has not been dispensed and a notification transaction RxFill <FillStatus><NotDispensed> is sent to the prescribing
physician. This is the same as Example 11.
Transaction
RxFill - not dispensed (from Pharmacy)
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RxFill - FillStatus/NotDispensed
Prescriber
Pharmacy
Status
RxFill - not dispensed (from Pharmacy)
Notes:
Element Value Note
NotDispensed NotDispensed Denoting prescription has not been dispensed.
1.13 EXAMPLE 13. NOTIFY PRESCRIBER A PRESCRIPTION HAS BEEN PARTIALLY DISPENSED (VIA DIRECT
CONNECT)
In this example a NewRx is sent directly from the prescriber to the pharmacy. It is assumed there is a direct connect connection (dedicated line)
between the prescriber (clinic) and pharmacy. This scenario also shows two partial dispensing notifications RxFill
<FillStatus><PartiallyDispensed> sent to the prescriber for the NewRx. There is no completion transaction. The final partial dispensing message
will indicate quantity received and may also optionally include quantity remaining.
Transaction
RxFill – partially dispensed (from Pharmacy)
RxFill - partially dispensed (from Pharmacy)
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100 qty
NewRx
Status
Elapsed Time
60 qty
RxFill – FillStatus/PartiallyDispensed
Prescriber
Pharmacy
Status
Elapsed Time
40 qty
RxFill – FillStatus/PartiallyDispensed
Status
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NewRx from Prescriber RxFill from Pharmacy RxFill from Pharmacy
<MessageID> 1234567 A66 A67
Status from Pharmacy Status from Prescriber Status from Prescriber
<MessageID> ABC11 33333 33334

<RelatesToMessageID> 1234567 A66 A67
<RxReferenceNumber>
Notes:
Element Value Note
01T08:15:22

<Header>
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<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxFill>
<FillStatus>
<PartiallyDispensed>
<Note>OUT OF STOCK</Note>
</PartiallyDispensed>
</FillStatus>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
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</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
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<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<LastFillDate>
<Date>2010-11-01</Date>
</LastFillDate>
<Sig>
</Sig>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>100</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
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<Sig>
</Sig>
</RxFill>
</Body>
</Message>
Notes:
Only pertinent elements are shown.
Element Value Note
ease
PartiallyDispensed PartiallyDispensed Denoting prescription has been partially dispensed.
Note OUT OF STOCK Explanation why prescription was only partially dispensed.
MedicationDispensed
DrugDescription PCE 333 MG Drug prescribed is PCE 333 MG.
for “Tablet dosing form”. So this means the prescription is for 240mg tablets
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Element Value Note
LastFillDate 2010-11-01 Date last filled 11/01/2010.
DrugDescription PCE 333 MG Drug prescribed is PCE 333 MG.
Quantity 100:38 The quantity is 60. 38 is the code value for Original Quantity.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
A day later…

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123
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxFill>
<FillStatus>
<PartiallyDispensed>
</PartiallyDispensed>
</FillStatus>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
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<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
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<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>40</Value>
<Code>C48542</Code>
</Quantity>
<LastFillDate>
<Date>2010-11-02</Date>
</LastFillDate>
<Sig>
</Sig>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>100</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
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<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</RxFill>
</Body>
</Message>
Notes:
Element Value Note
ease
PartiallyDispensed PartiallyDispensed Denoting prescription has been partially dispensed.
MedicationDispensed

<Header>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.14 EXAMPLE 14: RXFILL - DISPENSED PROFILE MEDICATION (FROM PHARMACY TO LTPAC FACILITY)
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxFill>
<FillStatus>
<Dispensed>
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<Note>PROFILE MEDICATION APPROPRIATE FOR ADMINISTRATION</Note>
<ReasonCode>DH</ReasonCode>
</Dispensed>
</FillStatus>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
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<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>0</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
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</RxFill>
</Body>
</Message>
Notes:
Element Value Note
ease
Dispensed Dispensed Denoting the prescription has been dispensed.
ReasonCode DH Denoting profile medication.
Note Profile medication. The prescription has been place on the patients profile for possible
dispensing on a future date.
MedicationDispensed
Quantity 0:87 The quantity is 0, this is a profile medication. 87 is the code value for
Quantity Received.

<Header>
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131
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.15 EXAMPLE 15. CANCEL A PRESCRIPTION PREVIOUSLY SENT TO THE PHARMACY

In this example a prescription cancellation request is sent from the prescriber to the pharmacy. The pharmacy acknowledges the cancellation by
sending a cancel prescription response back to the prescriber.
Transaction
CancelRx (from Prescriber)
CancelRxResponse (from Pharmacy)
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CancelRx
Status
Prescriber
Pharmacy
CancelRxResponse
Status
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133
NewRx from Prescriber CancelRx from Prescriber CancelRxResponse from
Pharmacy
<MessageID> 1234567 U77 8889
<RelatesToMessageID> 1234567 U77
<RxReferenceNumber>
Status from Pharmacy Status from Pharmacy Status from Prescriber
<MessageID> ABC11 8887 U99

<RelatesToMessageID> 1234567 U77 8889
<RxReferenceNumber>
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 1234567 at 08:15:22.

<Header>
<MessageID>U77</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<CancelRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
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135
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</CancelRx>
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136
</Body>
</Message>
Notes:
Element Value Note
the destination.
MessageID U77 Clinic system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234567 Prescriber system trace number is used to link the original transaction
(NewRx) (MessageID) to this subsequent transaction.
SecondaryIdentification PASSWORDQ The password of the Clinic.
01T08:19:22
ease
RxReferenceNumber Not applicable. Not sent.
CancelRx CancelRx The transaction type: Cancel Prescription.
Address
Gender F Female
ROAD:JONESVILLE:T
N:37777
Strength 240 240 is the strength.
StrengthForm C42998 The Source for NCPDP Drug Dosage Form Terminology. C42998 is the code for
“Tablet dosing form”. So this means the prescription is for 240mg tablets.
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Element Value Note

TWO TIMES A DAY
UNTIL GONE

<Header>
<RelatesToMessageID>U77</RelatesToMessageID>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
CancelRxResponse (from Pharmacy)

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138
<Header>
<RelatesToMessageID>U77</RelatesToMessageID>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<CancelRxResponse>
<Response>
<Approved>
</Approved>
</Response>
</CancelRxResponse>
</Body>
</Message>
Notes:
Element Value Note
To 77777777:C This is the Clinic ID of the sender; C means it is a Clinic
the destination.
RelatesToMessageID U77 Prescriber system trace number is used to link the original transaction
(CancelRx) (MessageID) to this subsequent transaction.
SecondaryIdentification PASSWORD5 The password of the Pharmacy
CancelRxResponse CancelRxResponse The transaction type: Cancel Prescription Response.
01T08:19:24
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139
Element Value Note
RxReferenceNumber Not applicable. Not sent.
Approved Approved Denoting prescription successfully processed.

<Header>
<MessageID>U99</MessageID>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P Pharmacy; P means Pharmacy. Now the destination.
From 77777777:C Clinic ID. Now the sender.
MessageID U99 Clinic system trace number for the transmission. Echoed back in the
RelatesToMessageID 8889 Pharmacy system trace number is used to link the (MessageID) from request
to the response.
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Element Value Note
Code 000 The status type  000 means no error.
Description STATUS CODE... Text version of status.
1.16 EXAMPLE 16. PHARMACY REQUESTS ALTERNATIVE DRUG TO PRESCRIBED

In this example, the prescriber has already submitted a NewRx for Methyldopa. The pharmacy requests the alternatives of Clonidine and
Guanabenz. Clonidine is the first alternative sent and therefore the preferred alternative. The pharmacy and prescriber are directly connected.
Transaction
...
RxChangeRequest
Status
Prescriber
Pharmacy
(after time elapse)
RxChangeResponse
Status
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141
NewRx from Prescriber RxChangeRequest from RxChangeResponse from
Pharmacy Prescriber
<MessageID> 2234567 6699 2291
<RxReferenceNumber>
Status from Pharmacy Status from Prescriber Status from Pharmacy
<MessageID> ABC11 66666691 66666692

<RelatesToMessageID> 2234567 6699 2291
<RxReferenceNumber>
The pharmacy has not yet assigned a prescription number <RxReferenceNumber> on their system.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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142
</SenderSoftware>
</Header>
<Body>
<RxChangeRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
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143
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>METHYLDOPA</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>ONE TABLET ORALLY FOUR TIMES A DAY </SigText>
</Sig>
<DrugDescription>CLONIDINE</DrugDescription>
<DrugCoded>
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144
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
<SigText>ONE TABLET ORALLY FOUR TIMES A DAY</SigText>
</Sig>
<DrugDescription>GUANABENZ</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
<SigText>ONE TABLET ORALLY FOUR TIMES A DAY</SigText>
</Sig>
</RxChangeRequest>
</Body>
</Message>
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Notes:
Element Value Note
ase
RxReferenceNumber Not yet assigned by pharmacy system.
RxChangeRequest RxChangeRequest The transaction type: Prescription Change Request.
MessageRequestCode T Therapeutic interchange/substitution is being requested.
Gender F Female
Address
ROAD:JONESVILLE:T
N:37777
DrugDescription METHYLDOPA Methyldopa is the prescribed drug.
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146
Element Value Note
WrittenDate 2010-10-01:102 Date Written 10/1/2010.

NumberOfRefills 3 Three refills are allowed.
SigText ONE TABLET ORALLY ONE TABLET ORALLY… is the Sig.
FOUR TIMES A DAY
MedicationRequested
DrugDescription CLONIDINE Clonidine is a suggested alternative drug. Since it is first in the Requested
loops, it is the preferred drug.

SigText 1 TABLET ORALLY 1 TABLET ORALLY… is the Sig.
FOUR TIMES A DAY
MedicationRequested
DrugDescription GUANABENZ Guanabenz is a suggested alternative drug.
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147
Element Value Note
SigText ONE TABLET ORALLY ONE TABLET ORALLY… is the Sig.
FOUR TIMES A DAY

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
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148
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved/>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
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</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>CLONIDINE</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
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<Sig>
<SigText>ONE TABLET ORALLY TWICE A DAY</SigText>
</Sig>
</RxChangeResponse>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID 6699 Pharmacy trace number is used to link the original transaction
01T09:24:36
ease
RxReferenceNumber Not yet assigned by the pharmacy system.
RxChangeResponse RxChangeRespon The transaction type: Prescription Change Response.
se
Approved Approved The request for therapeutic interchange/substitution was approved by the
prescriber.
Gender F Female
Address
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Element Value Note
ROAD:JONESVILL
E:TN:37777
DrugDescription CLONIDINE The prescriber has accepted the change to Clonidine.
StrengthForm C42998 The Source for NCPDP Drug Dosage Form Terminology- C42998 is the code for
“Tablet dosing form”.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology - C28253 is the
code for “Milligram”.
QuantityUnitOfMeasure C48542 The Source for NCPDP QuantityUnitOfMeasure Terminology- C48542 is the code
for “Tablet”.
WrittenDate 2010-10-01
NumberOfRefills 0 No refills.
SigText ONE TABLET ONE TABLET ORALLY… is the Sig.
ORALLY TWICE A
DAY

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
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</Body>
</Message>
1.17 EXAMPLE 17. PRESCRIPTION CHANGE REQUEST FROM PHARMACY FOR PRIOR AUTHORIZATION (EXCERPT)
In this example, the pharmacy recognizes before the prescription can be dispensed, a prior authorization must be fulfilled. This example contains
only the RxChangeRequest from the pharmacy, with different examples of what a RxChangeResponse might be from the prescriber.
The trace number <MessageID> assigned by the prescribing system when they sent the new prescription was 123488.
Notes:
Element Value Note
MessageRequestCode P Prior Authorization required
RxChangeResponse (from Prescriber) without PA number [response is authorized]

Notes:
Element Value Note
Approved Approved
OR RxChangeResponse (from Prescriber) with PA number [response is authorized]

Notes:
Element Value Note
Approved Approved
PriorAuthorization 1234567 Prior Authorization number sent from the prescriber
OR RxChangeResponse (from Prescriber) PA request [response is denied]

Notes:
Element Value Note
Denied Denied
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Element Value Note
ReasonCode AO No attempt will be made to obtain Prior Authorization
1.18 EXAMPLE 18. PRESCRIPTION CHANGE REQUEST FROM PHARMACY FOR AN EXISTING "FILLABLE"
PRESCRIPTION (EXCERPT)
The reference number <PrescriberOrderNumber>assigned by the prescribing system when they sent the NewRx was 1212.
In this example the patient has an existing "fillable" prescription on file at the pharmacy for a medication that is now available as a generic.
Notes:
Element Value Note
Note SUBSTITUTE Pharmacy is asking to substitute generic.
GENERIC?
DrugDescription GLUCOTROL
XL5MG
“Tablet dosing form”.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology - C28253 is the
code for “Milligram”.
QuantityUnitOfMeasure C48542 The Source for NCPDP QuantityUnitOfMeasure Terminology- C48542 is the code
for “Tablet”.
WrittenDate 2010-10-01
NumberOfRefills 0 No refills.
In this example the patient has an existing "fillable" prescription on file at the pharmacy for a medication that has been discontinued. Pharmacy
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is requesting a therapeutic change. The pharmacy may or may not suggest alternatives for the prescriber.
Notes:
Element Value Note
MessageRequestCode T Therapeutic substitution is being requested.
Note THIS Pharmacy is asking to substitute.
MEDICATION IS
NO LONGER
AVAILABLE
DrugDescription GUAIFENESIN The prescriber has accepted the change to Clonidine.
1200MG ER
TABLETS
In this example the patient has an existing "fillable" prescription on file at the pharmacy for a medication that now requires a prior authorization
from the health plan.
Notes:
Element Value Note
MessageRequestCode P Prior authorization is being requested.
Note MEDICATION
REQUIRES PRIOR
AUTHORIZATION
CALL 1-800-555-
5555
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1.19 EXAMPLE 19. PRESCRIBER REQUESTS MEDICATION HISTORY
In this example, the prescriber is requesting historical drug information for a patient between the date range of 01/01/2010 and 12/01/2010.
There are two prescriptions that are known to the payer.
Transaction
RxHistoryRequest (from Prescriber)
RxHistoryResponse (from Payer)
RxHistoryRequest from
Prescriber
Field Name Value
<MessageID> 9991
<RxReferenceNumber>
RxHistoryResponse from
Payer
<MessageID> Z22
<RxReferenceNumber>

<Header>
<To Qualifier="ZZZ">PAYER123</To>
<Security>
<UsernameToken>
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</UsernameToken>
<Sender>
<SecondaryIdentification>PWPHY</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxHistoryRequest>
<BenefitsCoordination>
<PayerIdentification>
<IINNumber>PBM123</IINNumber>
</PayerIdentification>
<PayerName>PBM COMPANY</PayerName>
<CardholderID>CARDHOLDERID</CardholderID>
<CardHolderName>
<LastName>JAMES</LastName>
<FirstName>TINA</FirstName>
</CardHolderName>
<GroupID>GROUPNUMBER</GroupID>
<PayerResponsibilityCode>P</PayerResponsibilityCode>
<Consent>Y</Consent>
</BenefitsCoordination>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1944-06-05</Date>
</DateOfBirth>
</HumanPatient>
</Patient>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>3334444</NPI>
</Identification>
<Name>
<LastName>JONSON</LastName>
<FirstName>TIM</FirstName>
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</Name>
<Address>
<AddressLine1>151 EAST STREET</AddressLine1>
<City>CLYDE</City>
<StateProvince>ME</StateProvince>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<RequestedDates>
<StartDate>
<Date>2010-01-01</Date>
</StartDate>
<EndDate>
<Date>2010-12-01</Date>
</EndDate>
</RequestedDates>
</RxHistoryRequest>
</Body>
</Message>
Notes:
Element Value Note
To PAYER123:ZZZ This is the ID of the receiver; ZZZ means it is mutually defined between
trading partners.
From 77777777:C This is the Clinic ID of the prescriber; C means it is a Clinic. This is the sender.
01T08:13:22
SecondaryIdentification PWPHY This is the password of the prescriber system.
ase
RxHistoryRequest RxHistoryRequest The transaction type: Medication History Request
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Element Value Note
BINLocationNumber PBM123 Payer ID: PBM123.
PayerName PBM COMPANY Payer Name
CardholderID CARDHOLDERID Cardholder ID
Cardholder LastName, First JAMES, TINA Cardholder name of Tina James
Name
GroupID GROUPNUMBER Group ID
PayerResponsibilityCode P Primary
Consent Y Patient gave consent for prescriber to receive the medication history from
any prescriber.
PBMMemberID MEMBERID The Patient Identifier obtained.
LastName, FirstName JAMES:TINA Patient’s Name: Tina James
Gender F Female
LastName, FirstName JONSON:TIM The prescriber’s name: Tim Jonson
Address 151 EAST The prescriber’s address.
STREET:CLYDE:ME:1
1122
EffectiveDate 2010-01-01 Effective Date (Begin) is 01/01/2010. This is the start date requested of the
medication history search.
ExpirationDate 2010-12-01 Expiration Date is 12/01/2010. This is the end date requested of the

<Header>
<From Qualifier="ZZZ">PAYER123</From>
<MessageID>Z22</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
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</Security>
<SenderSoftware>
<SenderSoftwareDeveloper>MD80SYSTEM</SenderSoftwareDeveloper>
</SenderSoftware>
</Header>
<Body>
<RxHistoryResponse>
<Response>
<Approved/>
</Response>
<PayerIdentification>
<IINNumber>PBM123</IINNumber>
</PayerIdentification>
<PayerName>PBM COMPANY</PayerName>
<CardholderID>CARDHOLDERID</CardholderID>
<CardHolderName>
</CardHolderName>
<GroupID>GROUPNUMBER</GroupID>
<PayerResponsibilityCode>P</PayerResponsibilityCode>
<Consent>Y</Consent>
<PBMMemberID>MEMBERID</PBMMemberID>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1944-06-05</Date>
</DateOfBirth>
</HumanPatient>
</Patient>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>3334444</NPI>
</Identification>
<Name>
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</Name>
<Address>
<City>CLYDE</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>MEDROL DOSEPAK</DrugDescription>
<DrugCoded>
<ProductCode>
<Code>00009005604</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>21</Value>
<Code>C648542</Code>
</Quantity>
<LastFillDate>
<Date>2010-11-15</Date>
</LastFillDate>
<RefillsRemaining>1</RefillsRemaining>
<Pharmacy>
<Identification>
<NPI>1212121212</NPI>
</Identification>
<BusinessName>FIRST STREET PHARMACY</BusinessName>
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<PrimaryTelephone>
</PrimaryTelephone>
<Fax>
</Fax>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>3334444</NPI>
</Identification>
<Name>
</Name>
<Address>
<City>CLYDE</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>METFORMIN HCL 850 MG TABLET</DrugDescription>
<DrugCoded>
<ProductCode>
<Code>00378024001</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
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<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<LastFillDate>
<Date>2010-10-21</Date>
</LastFillDate>
<Pharmacy>
<Identification>
<NPI>1212121212</NPI>
</Identification>
<BusinessName>FIRST STREET PHARMACY</BusinessName>
<PrimaryTelephone>
</PrimaryTelephone>
<Fax>
</Fax>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>3334444</NPI>
</Identification>
<Name>
</Name>
<Address>
<City>CLYDE</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
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<RequestedDates>
<StartDate>
<Date>2010-01-01</Date>
</StartDate>
<EndDate>
<Date>2010-12-01</Date>
</EndDate>
</RequestedDates>
</RxHistoryResponse>
</Body>
</Message>
Notes:
Element Value Note
To 77777777:C This is the Clinic ID of the prescriber system; C means it is a Clinic. This is the
receiver.
From PAYER123:ZZZ This is the ID of the sender; ZZZ means it is mutually defined between trading
partners.
MessageID Z22 Payer system trace number for the transmission. Echoed back in the
response.
SentTime 2011-01- Date and time transaction was sent 01/01/2011 at 08:13:23
01T08:13:23
SenderSoftwareDeveloper MD80SYSTEM:80:15. Sender Software Developer: MD80SYSTEM
, SenderSoftwareProduct, 2 Sender Software Product: 80
ease
RxHistoryResponse RxHistoryResponse The transaction type: Medication History Response
Approved Approved
Cardholder LastName, JAMES, TINA Cardholder name of Tina James
First Name
PBMMemberID MEMBERID The Patient Identifier returned.
Gender F Female
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Element Value Note
STREET:CLYDE:ME:1
1122
any prescriber.
MedicationDispensed
DrugDescription MEDROL DOSEPAK MEDROL DOSEPAK is the drug dispensed.
ProductCode and Qualifier 00009005604:ND 00009005604 is the NDC. ND is qualifier for NDC.
for “Tablet dosing form”. So this means the prescription is for 4 mg Tablet
dosing form.
Quantity 21:87 The quantity is 21. 87 is rthe code value for Quantity Received.
LastFillDate 2010-11-15 Last Demand (Last Fill) 11/15/2010.
RefillsRemaining 1 1 refill remaining
Prescriber Information about the prescriber for the medication MEDROL DOSEPACK.
Pharmacy Pharmacy that dispensed MEDROL DOSEPACK.
NCPDPID 2234567 2234567 is the NCPDP Provider ID for the pharmacy that dispensed
MEDROL DOSEPACK.
StoreName FIRST STREET The pharmacy that dispensed the prescription MEDROL DOSEPACK.
PHARMACY
CommunicationNumber 6512219001 Telephone number of the pharmacy (651) 221-9001.
CommunicationNumber 6512219000 Fax number of the pharmacy (651) 221-9000.

STREET:CLYDE:ME:1
1122
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Element Value Note
MedicationDispensed
DrugDescription METFORMIN HCL METFORMIN HCL 850 MG TABLET is the drug dispensed.
850 MG TABLET
Product Code and 00378024001:ND 00378024001 is the NDC. ND is the qualifier.
Qualifier
“Tablet dosing form”. So this means the prescription is for 850 mg tablets.
Quantity 60:87 The quantity is 60. 87 is Quantity Received.
RefillsRemaining 2 Two refills remaining.
Pharmacy Pharmacy that dispensed METFORMIN
NCPDPID 2234567 2234567 is the NCPDP Provider ID for the pharmacy that dispensed
METFORMIN.
StoreName FIRST STREET The pharmacy that dispensed the prescription METFORMIN.
PHARMACY
CommunicationNumber 6512219001 Telephone number of the pharmacy (651) 221-9001.
CommunicationNumber 6512219000 Fax number of the pharmacy (651) 221-9000.
Prescriber Information about the prescriber for the medication METFORMIN.
STREET:CLYDE:ME:1
1122
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1.20 EXAMPLE 20. PRESCRIBER SENDS THE ORIGINAL ORDER, THEN CHANGES THE ORIGINAL ORDER,
SIGNIFICANTLY (DIRECT CONNECT)
In this example, the physician originally prescribed a drug. After the order was active, the physician changes the dosage of the drug prescribed.
Transaction
NewRx from Prescriber CancelRx from Prescriber CancelRxResponse from NewRx from Prescriber
Pharmacy
<MessageID> 1234567 1234569 ABC445 1234568
<RxReferenceNumber>
Status from Pharmacy Status from Pharmacy Status from Prescriber Status from Pharmacy
<MessageID> ABC11 ABC22 1235541 ABC88

<RelatesToMessageID> 1234567 1234569 ABC445 1234568
<RxReferenceNumber>
Notes:
Element Value Note
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Element Value Note
Gender F Female
Address 45 EAST ROAD The Patient’s Address.
SW:CLANCY:WI:5499
9
ROAD:JONESVILLE:T
N:37777
BINLocationNumber 123456 Primary Payer’s identification number.
PayerName INSURANCE Name of Payer.
COMPANY NAME
CardholderID 123456789 Cardholder ID.
GroupID AA112 Group ID.

NumberOfRefills 1 1 refill
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Element Value Note
TWO TIMES A DAY
UNTIL GONE

Transaction
Notes:
Element Value Note
RelatesToMessageID 1234567 Prescriber trace number is used to link the original transaction (NEWRX)
CancelRx CancelRx The transaction type: Cancel Prescription
MessageRequestCode C1 Indicates that this order is a significant change of an existing order.
Gender F Female
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Element Value Note
ROAD:JONESVILLE:T
N:37777
COMPANY NAME

TWO TIMES A DAY
UNTIL GONE
Prescriber updates the Dosage

NewRx from the Prescriber
Transaction
Notes:
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Element Value Note
MessageRequestCode C1 Indicates that this order is a significant change of an existing order.
Gender F Female
CLANCY, WI, 54999,
US
ROAD:JONESVILLE:T
N:37777
SW:CLANCY:WI:5499
9, US
COMPANY NAME
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Element Value Note

TWO TIMES A DAY
UNTIL GONE
1.21 EXAMPLE 21. PRESCRIBER REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE

ELEMENT
In this example, the prescriber is requesting historical drug information for a patient between the date range of 01/01/2010 and 12/01/2010.
There are two prescriptions that are known to the payer. See Example 18 for detail.

Notes:
Element Value Note
Approved Approved
MedicationDispensed
HistorySource PY SourceQualifier of Payer (PY).
SourceQualifier
SourceDescription PAYER123
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Element Value Note
Reference IDValue and PBM123:2U Reference Number of the Source Description – Payer Identification Number (2U)
Qualifier
SourceReference 12345 Prescription Number from payer system from claims processing.
FillNumber 01 Fill Number from payer system from claims processing = 01 (First Refill)
MedicationDispensed
DrugDescription METFORMIN METFORMIN HCL 850 MG TABLET is the drug dispensed.
HCL 850 MG
TABLET
SourceQualifier
Reference ID Value and PBM123:2U Reference Number of the Source Description – Payer Identification Number (2U)
Qualifier
1.22 EXAMPLE 22. PHARMACY REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE

ELEMENT
In this example, the pharmacy is requesting historical drug information for a patient between the date range of 01/01/2010 and 12/01/2010.
There are two prescriptions that are known to the aggregator. Per the rules in Section “Specific Element Discussion”, subsection “Source
Element”, the <Pharmacy> and specific pharmacy identification in the <Source> is not allowed to be returned in the Medication History response
when the requester is a pharmacy.
Transaction
RxHistoryRequest (from Pharmacy)
RxHistoryResponse (from Aggregator)
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Pharmacy
Field Name Value
<MessageID> A88
<RxReferenceNumber>
Aggregator
<MessageID> X222
<RelatesToMessageID> A88
<RxReferenceNumber>

Notes:
Element Value Note
To AGGREGATOR:ZZZ This is the ID of the receiver; ZZZ means it is mutually defined between
trading partners.
sender.
SecondaryIdentification PASSWORDB This is the password of the pharmacy system.
SentTime 2011-01-01:08:13:22 Date and time transaction was sent 01/01/2011 08:13:22 A.M.
SenderSoftwareDeveloper ACE Sender Software Developer: ACE SOFTWARE
, SenderSoftwareProduct, SOFTWARE:ACE1:1.1 Sender Software Product: ACE1
ease
Gender F Female
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Element Value Note
STREET:CLYDE:ME:1
1122
First Name
any prescriber.
RxHistoryResponse (from Aggregator)

Notes:
Element Value Note
receiver.
From AGGREGATOR:ZZZ This is the ID of the sender; ZZZ means it is mutually defined between trading
partners.
MessageID X222 Aggregator system trace number for the transmission. Echoed back in the
RelatesToMessageID A88 Pharmacy trace number is used to link the (MessageID) from request to the
response.
01:08:13:23
SenderSoftwareDeveloper MD80SYSTEM:80:15 Sender Software Developer: MD80SYSTEM
, SenderSoftwareProduct, .2 Sender Software Product: 80
ease
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Element Value Note
Approved Approved
First Name
Consent Y Patient gave consent for prescriber to receive the medication history from any
prescriber.
PBMMemberID MEMBERID The Patient Identifier returned from the payer.
Gender F Female
STREET:CLYDE:ME:1
1122
MedicationDispensed
“Tablet Dosage Form”. So this means the prescription is for 4 mg Tablet dosing
form.
SourceQualifier
Reference IDValue and PBM123:2U Reference Number of the Source Description – Payer Identification Number
Qualifier (2U)
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Element Value Note
STREET:CLYDE:ME:1
1122
MedicationDispensed
DrugDescription METFORMIN METFORMIN HCL 850 MG TABLET is the drug dispensed.
HCL 850 MG
TABLET
Qualifier
“Tablet dosing form”. So this means the prescription is for 850 mg tablets.
RefillsRemaining 2 Two refills remaining.
SourceQualifier
Reference IDValue and PBM123:2U Reference Number of the Source Description – Payer Identification Number
Qualifier (2U)
STREET:CLYDE:ME:1
1122
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Element Value Note
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1.23 EXAMPLE 23. SIG ELEMENT EXAMPLES
1.23.1 TEXT SIG EXAMPLES
If a system does not generate a structured Sig, then the complete free text instructions are to be conveyed in the <SigText> field. When only the
<SigText> is populated; no other Sig elements are populated.
1.23.1.1 Take One Tablet by Mouth Every Morning

<SIG xsi:noNamespaceSchemaLocation="samples.xsd" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<SIG>
<StructuredSIG>
<SigText>TAKE 1 TABLET BY MOUTH EVERY MORNING</SigText>
</StructuredSIG>
1.23.1.1 </SIG> Prednisone Tapering Dose Sig

<StructuredSIG>
<SigText>Take 4 tablets by mouth every day for 3 days,then take 3 tablets by mouth every day for 3 days,then take 2 tablets by mouth every day for 3 days,then take 1 tablet by mouth every day for 3 days</SigText>
</StructuredSIG>
</SIGSample>
1.23.2 STRUCTURED SIG EXAMPLES

In the examples,
1. The value SNOMED CODE or FMT CODE should contain the actual value from these vocabularies. Where possible, the actual value is
included in the following examples. Where not possible the clarifying free text requirements are shown.
2. <Qualifier> value is SNOMED or FMTDOSEFORM.
3. Only the elements necessary to relay the structured Sig are shown. Conditional elements are not shown when not applicable to the Sig.
4. It is recommended that the most recent version of the Code System be used; if not, trading partner agreement is required as to which
version is used.
5. When the structured Sig is sent, the <CodeSystem> is mandatory. There may be structured Sigs sent which based on their elements do
not use SNOMED or FMT Term from NCI for dose form. However, the recommendation is that both <SNOMEDVersion> and
<FMTVersion> are mandatory elements. Each system that supports structured Sig will need to support the SNOMED and FMT Term from
NCI for dose form for some Sigs they will send or receive. Therefore, the system should have the ability to populate a default version
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they support.
1.23.2.1 Take One Tablet by Mouth Every Morning

<SIGSample xsi:noNamespaceSchemaLocation="samples.xsd" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<StructuredSIG>
<SigText>Take 1 tablet oral route1 PER day morning</SigText>
<CodeSystem>
<SNOMEDVersion>20160901</SNOMEDVersion>
<FMTVersion>16.03d</FMTVersion>
</CodeSystem>
<Instruction>
<DoseAdministration>
<DoseDeliveryMethod>
<Text>Take</Text>
<Qualifier>SNOMED</Qualifier>
<Code>419652001</Code>
</DoseDeliveryMethod>
<Dosage>
<DoseQuantity>1</DoseQuantity>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Qualifier>DoseUnitOfMeasure</Qualifier>
<Code>C48542</Code>
</DoseUnitOfMeasure>
</Dosage>
<RouteOfAdministration>
<Text>oral route</Text>
<Code>26643006</Code>
</RouteOfAdministration>
</DoseAdministration>
<TimingAndDuration>
<Frequency>
<FrequencyNumericValue>1</FrequencyNumericValue>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</TimingAndDuration>
<TimingAndDuration>
<AdministrationTiming>
<AdministrationTimingEvent>
<Text>morning</Text>
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<Code>814200017</Code>
</AdministrationTimingEvent>
</AdministrationTiming>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.2 Take 1 Tablet By Mouth Twice A Day

<StructuredSIG>
<SigText>Take 1 tablet oral route 2 per day</SigText>
<CodeSystem>
<SNOMEDVersion>2017_03_01</SNOMEDVersion>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
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</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.3 Take 1 Tablet By Mouth At Bedtime

<StructuredSIG>
<SigText>Take 1 tablet oral route 1 day bedtime</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>Bedtime</Text>
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<Code>21029003</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.4 Take 1 Tablet By Mouth 3 Times A Day

<StructuredSIG>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
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</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.5 Take As Directed – Per Medical Encounter Instructions

<StructuredSIG>
<SigText>Per MEDICALENCOUNTER</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<InstructionIndicator>MEDICALENCOUNTER</InstructionIndicator>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.6 Take 1 Tablet By Mouth Every Morning

<StructuredSIG>
<SigText>Take tablet oral route 1 per day morning</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
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<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>Morning</Text>
<Code>73775008</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.7 Take 1 Tablet By Mouth Every Evening

<Sig>
<SigText>Take 1 tablet oral route 1 per day evening</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
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</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>Evening</Text>
<Code>3157002</Code>
</Instruction>
</Sig>
1.23.2.8 Take 1 Tablet By Mouth Every 6 Hours As Needed For Pain

<StructuredSIG>
<SigText>Take 1 tablet oral route every 6 hour as needed for pain</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
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<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalNumericValue>6</IntervalNumericValue>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
<IndicationPrecursor>
<Text>as needed for</Text>
<Code>420449005</Code>
</IndicationPrecursor>
<IndicationValue>
<Text>pain</Text>
<Code>22253000</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.9 Take 2 Tablets By Mouth As One Dose On the First Day Then Take One Tablet Daily (ZPak)
<StructuredSIG>
<SigText>Take 2 tablets oral route 1 per day for 1 day THEN take 1 tablet oral route per 1 day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
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<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationNumericValue>1</DurationNumericValue>
<DurationText>
<Text>day</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
<MultipleInstructionModifier>THEN</MultipleInstructionModifier>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
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<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.10 Take 2 Tablets By Mouth Every Day For 5 Days

<StructuredSIG>
<SigText>Take 2 tablets oral route 1 per day for 5 days</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
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<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>days</Text>
<Code>2620163013</Code>
</DurationText>
</Duration>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.11 Take 2 Tablets By Mouth Daily

<StructuredSIG>
<SigText>Take 2 tablets oral route 1 per day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
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<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.12 Take 1 Tablet By Mouth 4 Times A Day

<StructuredSIG>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
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<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.13 Take One Tablet By Mouth Every 6 Hours As Needed For Cough
<StructuredSIG>
<SigText>Take 1 tablet oral route every 6 hour as needed for cough</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
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</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
<Code>420449005</Code>
<IndicationValue>
<Text>cough</Text>
<Code>49727002</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.14 Take 2 Tablets By Mouth Twice Daily

<StructuredSIG>
<SigText>Take 2 tablets oral route 2 per day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
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<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.15 Take 1 Tablet By Mouth Every 6 To 8 Hours As Needed For Pain

<StructuredSIG>
<SigText>Take 1 tablet oral route every 6 to 8 hour as needed for pain</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
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<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<VariableIntervalModifier>TO</VariableIntervalModifier>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
<Code>420449005</Code>
<IndicationValue>
<Text>pain</Text>
<Code>22253000</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.16 Take 1 Tablet By Mouth Twice A Day For 10 Days

<StructuredSIG>
<SigText>Take 1 tablet oral route 2 per day for 10 day</SigText>
<CodeSystem>
</CodeSystem>
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<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>day</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.17 Take 1 To 2 Tablets By Mouth Every 4 To 6 Hours As Needed For Pain

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<StructuredSIG>
<SigText>Take 1 TO 2 tablets oral route every 4 TO 6 hour as needed for pain</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
<DoseRangeModifier>TO</DoseRangeModifier>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
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<Code>420449005</Code>
<IndicationValue>
<Text>pain</Text>
<Code>22253000</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.18 Take 1 Tablet By Mouth 3 Times A Day As Needed for Headache

<StructuredSIG>
<SigText>Take 1 tablet oral route 3 per day as needed for headache</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
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<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<IndicationForUse>
<Code>420449005</Code>
<IndicationValue>
<Text>headache</Text>
<Code>25064002</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.19 Take 1 Tablet By Mouth Every 12 Hours

<StructuredSIG>
<SigText>Take 1 tablet oral route every 12 hours</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
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<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hours</Text>
<Code>2620162015</Code>
</IntervalUnits>
</Interval>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.20 Take 1 Tablet By Mouth Twice A Day As Needed for Nausea

<StructuredSIG>
<SigText>Take 1 tablet oral route 2 per day as needed for nausea</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
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<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<IndicationForUse>
<Code>420449005</Code>
<IndicationValue>
<Text>nausea</Text>
<Code>422587007</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.21 Take 1 Tablet By Mouth Per Day As Directed during office visit
<StructuredSIG>
<SigText>Take 1 tablet oral rout per 1 day as directed during office visit </SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
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<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
<ClarifyingFreeText>as directed during office visit</ClarifyingFreeText>
</StructuredSIG>
</SIGSample>
1.23.2.22 Take 1 Tablet By Mouth At Bedtime As Needed for Sleep

<StructuredSIG>
<SigText>Take 1 tablet oral route 1 per day bedtime as needed for sleep</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
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<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Code>21029003</Code>
</Instruction>
<IndicationForUse>
<Code>420449005</Code>
<IndicationValue>
<Text>sleep</Text>
<Code>258158006</Code>
</IndicationValue>
</IndicationForUse>
</StructuredSIG>
</SIGSample>
1.23.2.23 Take 1 Tablet By Mouth Per Week

<StructuredSIG>
<SigText>Take 1 tablet oral route 1 per week</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
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<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>week</Text>
<Code>258705008</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.24 Take ½ Tablet By Mouth Daily

<StructuredSIG>
<SigText>Take 0.5 tablet oral route 1 per day </SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
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<Code>419652001</Code>
<Dosage>
<DoseQuantity>0.5</DoseQuantity>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.25 Instill 1 Drop in Both Eyes Twice Daily

<StructuredSIG>
<SigText>Instill 1 metric drop ophthalmic route in both eyes, entire 2 per day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Instill</Text>
<Code>421538008</Code>
<Dosage>
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<DoseUnitOfMeasure>
<Text>metric drop</Text>
<Code>C48491</Code>
</Dosage>
<Text> ophthalmic route</Text>
<Code>54485002</Code>
<SiteOfAdministration>
<Text>both eyes, entire</Text>
<Code>3620508001</Code>
</SiteOfAdministration>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.26 Take 1 Tablet By Mouth Every Other Day

<StructuredSIG>
<SigText>Take 1 tablet oral route 1 per every 2 day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
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<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>day</Text>
<Code>258703001</Code>
</IntervalUnits>
</Interval>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.27 Inhale 2 Puffs by Mouth 15 minutes Prior to Exercise

<StructuredSIG>
<SigText>Inhale 2 puff oral route 15 minutes before exercise</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Inhale</Text>
<Code>421134003</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>puff</Text>
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<Code>C65060</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>minutes</Text>
<Code>258701004</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<AdministrationTimingModifier>
<Text>Before</Text>
<Code>682904012</Code>
</AdministrationTimingModifier>
<Text>Exercise</Text>
<Code>2528895013</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.28 Apply 1 Patch to Skin Two Times a Day as Directed for Pain
<StructuredSIG>
<SigText>Apply 1 patch transdermal 2 per day as directed for pain</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
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<Text>Apply</Text>
<Code>417924000</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>patch</Text>
<Code>C48524</Code>
</Dosage>
<Text>transdermal</Text>
<Code>45890007</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<IndicationForUse>
<Text>as directed for</Text>
<Code>422135004</Code>
<IndicationValue>
<Text>pain</Text>
<Code>22253000</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.29 Apply 1 Patch to Skin Once PER Week as Directed During Office Visit
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<StructuredSIG>
<SigText>Apply 1 patch transdermal 1 per week as directed during office visit</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Apply</Text>
<Code>417924000</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>patch</Text>
<Code>C48524</Code>
</Dosage>
<Code>45890007</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>week</Text>
<Code>258705008</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
<ClarifyingFreeText>as directed during office visit</ClarifyingFreeText>
</StructuredSIG>
</SIGSample>
1.23.2.30 Inject 0.4mL Under the Skin Once a Day

<StructuredSIG>
<SigText>Inject 0.4 milliliter subcutaneous route 1 per day</SigText>
<CodeSystem>
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</CodeSystem>
<Instruction>
<Text>Inject</Text>
<Code>422145002</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>milliliter</Text>
<Code>C28254</Code>
</Dosage>
<Text>subcutaneous route</Text>
<Code>263887005</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.31 Apply sparingly to the Affected Area Two Times a Day

<StructuredSIG>
<SigText>Apply sparingly miligram topical route affected site 2 PER day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
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<Text>Apply</Text>
<Code>417924000</Code>
<DoseDeliveryMethodModifier>
<Text>sparingly</Text>
<Code>420883007</Code>
</DoseDeliveryMethodModifier>
<DoseAmount>
<Text>Unspecified</Text>
<Code>10003008</Code>
</DoseAmount>
<Text>topical route</Text>
<Text>affected site</Text>
<Code>263583002</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIG>
1.23.2.32 Take 1 Tablet by Mouth once a day on Monday, Wednesday, and Friday
<StructuredSIG>
<SigText>Take 1 tablet oral route 1 per day MONDAY 1 per day WEDNESDAY 1 per day FRIDAY</SigText>
<CodeSystem>
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</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>MONDAY</Text>
<Code>307145004</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
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</Frequency>
<TimingAndDuration>
<Text>WEDNESDAY</Text>
<Code>307148002</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>FRIDAY</Text>
<Code>307150005</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.33 Dissolve 1 Tablet Under the Tongue As Directed For Chest Pain
<StructuredSIG>
<SigText>Dissolve 1 tablet sublingual route as directed for chest pain</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Dissolve</Text>
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<Code>421682005</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Text>sublingual route</Text>
<Code>37839007</Code>
<TimingAndDuration>
<Text>non-specific</Text>
<Code>10003008</Code>
<IndicationForUse>
<Text>as directed for</Text>
<Code>422135004</Code>
<Indication>
<Text>CHEST PAIN</Text>
<Code>29857009</Code>
</Indication>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.34 Apply to Face Twice a Day

<StructuredSIG>
<SigText>Apply light - amount topical route entire face 2 per day </SigText>
<CodeSystem>
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</CodeSystem>
<Instruction>
<Text>Apply</Text>
<Code>417924000</Code>
<DoseAmount>
<Text>light - amount</Text>
<Code>672058011</Code>
</DoseAmount>
<Text>topical route</Text>
<Text>entire face</Text>
<Code>302549007</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.35 Instill 4 Drop in Left Ear 2 Times per Day for 10 Days
<StructuredSIG>
<SigText>Instill 4 metric drops otic route left ear structure 2 per day for 10 day.</SigText>
<CodeSystem>
</CodeSystem>
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<Instruction>
<Text>Instill</Text>
<Code>421538008</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>metric drop</Text>
<Code>C48491</Code>
</Dosage>
<Text>otic route</Text>
<Code>10547007</Code>
<Text>left ear structure</Text>
<Code>89644007</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>day</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
</StructuredSIG>
</SIGSample>
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1.23.2.36 Take 1 Tablet three times a week.
<StructuredSIG>
<SigText>Take 1 tablet oral route 3 per week</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>week</Text>
<Code>258705008</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.37 Take 1 Tablet By Mouth Every Morning on an Empty Stomach

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<StructuredSIG>
<SigText>Take 1 tablet oral route 1 PER day MORNING , on an empty stomach</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>tablet</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>MORNING</Text>
<Code>814200017</Code>
<TimingClarifyingFreeText>on an empty stomach</TimingClarifyingFreeText>
</Instruction>
</StructuredSIG>
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</SIGSample>
1.23.2.38 Use 2 Sprays in Each Nostril per Day

<StructuredSIG>
<SigText>Use 2 spray nasal route both anterior nares 1per day</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Use</Text>
<Code>419385000</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>spray</Text>
<Code>C48537</Code>
</Dosage>
<Text>nasal route</Text>
<Code>46713006</Code>
<Text>both anterior nares</Text>
<Code>244506005</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
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</StructuredSIG>
</SIGSample>
1.23.2.39 Apply ¼ inch Strip of Ointment in Both Eyes at Bedtime

<StructuredSIG>
<SigText>Apply 0.25 inch strip ophtalmic route both eyes, entire 1 PER day Bedtime</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Apply</Text>
<Code>417924000</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>inch strip</Text>
</Dosage>
<Text>ophtalmic route</Text>
<Code>54485002</Code>
<Text>both eyes, entire</Text>
<Code>362508001</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
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<TimingAndDuration>
<Code>750278017</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.40 Apply 1 Patch Behind Ear Every 72 Hours for Motion Sickness
<StructuredSIG>
<SigText>Apply 1 patch transdermal behind ear every 72 hours as needed for motion sickness</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Apply</Text>
<Code>417924000</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>patch</Text>
<Code>C48524</Code>
</Dosage>
<Code>45890007</Code>
<Text>behind ear</Text>
<Code>450941000124105</Code>
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<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
<Code>2617867013</Code>
<IndicationValue>
<Text>motion sickness</Text>
<Code>37031009</Code>
</IndicationValue>
</IndicationForUse>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.41 Insert 1 Ring Vaginally and Leave in Place for 3 Weeks, then Remove for 1 Ring-Free Week
<StructuredSIG>
<SigText>Insert 1 ring viginal route for 3 week, then remove for 1 ring viginal route for 1 week</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Insert</Text>
<Code>421257003</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>ring</Text>
<Code>C62609</Code>
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</Dosage>
<Text>vaginal route</Text>
<Code>16857009</Code>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>week</Text>
<Code>258705008</Code>
</DurationText>
</Duration>
</Instruction>
<Instruction>
<Text>Remove</Text>
<Code>421139008</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>ring</Text>
<Code>C62609</Code>
</Dosage>
<Text>vaginal route</Text>
<Code>16857009</Code>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>week</Text>
<Code>258705008</Code>
</DurationText>
</Duration>
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</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.42 Take 4 Capsules by Mouth 1 Hour Prior to Appointment Then Take 2 Capsules by Mouth 6 Hours Later
<StructuredSIG>
<SigText>Take 4 capsule oral route EVERY 1 hour , prior to appointment THEN Take 2 capsule oral route EVERY 6 hour, after appointment</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>capsule</Text>
<Code>C48480</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<TimingClarifyingFreeText>prior to appointment</TimingClarifyingFreeText>
</Instruction>
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<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Code>C48480</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<TimingClarifyingFreeText>after appointment</TimingClarifyingFreeText>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.43 Prednisone Tapering Dose Sig

This example illustrates how a system can create multiple data sets to build a tapering dose using modifiers to bridge to looping instructions.
<StructuredSIG>
<SigText>TAKE 4 TABLET oral route 1 PER DAILY FOR 3 DAYS THEN TAKE 3 TABLET Oral Route 1 PER DAILY FOR 3 DAYS THEN TAKE 2 TABLET oral route 1 PER DAILY FOR 3 DAYS THEN TAKE 1 TABLET oral route 1 PER
DAILY FOR 3 DAYS</SigText>
<CodeSystem>
</CodeSystem>
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<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>DAILY</Text>
<Code>69620002</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>DAYS</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
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<Dosage>
<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
</Dosage>
<Text>Oral Route</Text>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>DAILY</Text>
<Code>69620002</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>DAYS</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
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</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>DAILY</Text>
<Code>69620002</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>DAYS</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
</Dosage>
<Code>26643006</Code>
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<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>DAILY</Text>
<Code>69620002</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Duration>
<DurationText>
<Text>DAYS</Text>
<Code>258703001</Code>
</DurationText>
</Duration>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.44 Medrol DosePak – Use Per Manufacturer’s Instructions

This example shows the use of as directed per manufacturer’s packaging as an alternative to stating each individual repeating instruction.
<StructuredSIG>
<SigText>USE PER MANUFACTURER'S INSTRUCTIONS</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<AdministrationIndicator>MANUFACTURERSINSTRUCTIONS</AdministrationIndicator>
</Instruction>
</StructuredSIG>
</SIGSample>
Instead of sending the “As directed per manufacturer’s packaging”, the fully specified structured Sig could be sent:
• Day 1: 2 tablets before breakfast, 1 tablet after lunch, 1 tablet after dinner, 2 tablets at bedtime
• Day 2: 1 tablet before breakfast, 1 tablet after lunch, 1 tablet after dinner, 2 tablets at bedtime
• Day 3: 1 tablet before breakfast, 1 tablet after lunch, 1 tablet after dinner, 1 tablet at bedtime
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• Day 4: 1 tablet before breakfast, 1 tablet after lunch, 1 tablet at bedtime
• Day 5: 1 tablet before breakfast, 1 tablet at bedtime
• Day 6: 1 tablet before breakfast
1.23.2.45 Place 0.5 mL Buccally in each cheek 4 times a day after Feeding
This example illustrates a lesser used route of administration with a site of administration and a combination of timing elements. Note this again
does not reflect what might be placed on the prescription label. Note the implementer is to choose the codes that represent “4 times a day”
versus the codes for “every 4 days”.
<StructuredSIG>
<SigText>PLACE 0.5 mL BUCCALLY IN EACH CHEEK 4 Per DAY AFTER FEEDING.</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>PLACE</Text>
<Code>421066005</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>mL</Text>
<Code>C28254</Code>
</Dosage>
<Text>BUCCALLY</Text>
<Code>54471007</Code>
<Text>UNSPECIFIED</Text>
<Code>10003008</Code>
<SiteOfAdministrationClarifyingFreeText>IN EACH CHEEK</SiteOfAdministrationClarifyingFreeText>
<TimingAndDuration>
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<Frequency>
<FrequencyUnits>
<Text>DAY</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>AFTER FEED</Text>
<Code>309603005</Code>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.46 650 mg Twice Daily and every 4 hours as needed for Headache to max of 3900 MG per day
This example combines a scheduled and PRN order which is commonly seen in long term care settings.
<StructuredSIG>
<SigText> TAKE 650 Milligram Oral Route 2 PER DAILY AND TAKE 650 Milligram Oral Route EVERY 4 HOURS AS NEEDED FOR HEADACHE OR MAXIMUM OF 3900 MG PER DAY</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>Milligram</Text>
<Code> C28253</Code>
</Dosage>
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<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>DAILY</Text>
<Code>69620002</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
<MultipleInstructionModifier>AND</MultipleInstructionModifier>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>HOURS</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
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<Text>AS NEEDED FOR</Text>
<Code>420449005</Code>
<Indication>
<Text>HEADACHE</Text>
<Code>25064002</Code>
</Indication>
</IndicationForUse>
<MaximumDoseRestriction>
<MaximumDoseRestrictionNumericValue>3900</MaximumDoseRestrictionNumericValue>
<MaximumDoseRestrictionForm>
</MaximumDoseRestrictionForm>
<MaximumDoseRestrictionDurationValue>1</MaximumDoseRestrictionDurationValue>
<MaximumDoseRestrictionDurationUnit>
<Text>DAY</Text>
<Code>258703001</Code>
</MaximumDoseRestrictionDurationUnit>
</MaximumDoseRestriction>
</Instruction>
</StructuredSIG>
</SIGSample>
1.23.2.47 Take 1 tablet by mouth weekly, on an empty stomach, 30 to 60 minutes before breakfast with 8-12 ounces of
water. Do not lie down for one hour after taking.
This example illustrates difference between loops of instructions.
<StructuredSIG>
<SigText>TAKE 1 TABLET WITH 8 TO 12 OUNCES WATER BY MOUTH EVERY WEEK 30 TO 60 MINUTES BEFORE BREAKFAST ON EMPTY STOMACH, DO NOT LIE DOWN AFTER TAKING.</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>TAKE</Text>
<Code>419652001</Code>
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<Dosage>
<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
</Dosage>
<Vehicle>
<VehiclePreposition>
<Text>WITH</Text>
<Code>421463005</Code>
</VehiclePreposition>
<VehicleQuantity>8</VehicleQuantity>
<MultipleVehicleModifier>TO</MultipleVehicleModifier>
<VehicleQuantity>12</VehicleQuantity>
<VehicleUnitOfMeasure>
<Text>OUNCES</Text>
<Code>258692008</Code>
</VehicleUnitOfMeasure>
<Vehicle>
<Text>WATER</Text>
<Code>11713004</Code>
</Vehicle>
</Vehicle>
<Text>BY MOUTH</Text>
<Code>26643006</Code>
<TimingAndDuration>
<Text>EVERY</Text>
<Code>421612001</Code>
<Text>WEEK</Text>
<Code>258705008</Code>
<TimingAndDuration>
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<AdministrationTimingNumericValue>30</AdministrationTimingNumericValue>
<VariableAdministrationTimingModifier>TO</VariableAdministrationTimingModifier>
<AdministrationTimingNumericValue>60</AdministrationTimingNumericValue>
<AdministrationTimingUnits>
<Text>MINUTES</Text>
<Code>258701004</Code>
</AdministrationTimingUnits>
<Text>BEFORE</Text>
<Code>288556008</Code>
<Text>BREAKFAST</Text>
<Code>307160001</Code>
<AdministrationTimingClarifyingFreeText>ON EMPTY STOMACH</AdministrationTimingClarifyingFreeText>
</Instruction>
<ClarifyingFreeText> DO NOT LIE DOWN FOR ONE HOUR AFTER TAKING.</ClarifyingFreeText>
</StructuredSIG>
</SIGSample>
1.23.2.48 Place 1 Tablet Sublingual Every 5 Minutes as Needed for Chest Pain. Not More than 3 Tablets in 15 Minutes or 6
Tablets per Day
This example illustrates the use of multiple Maximum Dose Restrictions.
<StructuredSIG>
<SigText>PLACE 1 TABLET SUBLINGUAL EVERY 5 MINUTES AS NEEDED FOR CHEST PAIN MAXIMUM OF 3 TABLET PER 15 MINUTES Or 6 tablets per day </SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>PLACE</Text>
<Code>421066005</Code>
<Dosage>
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<DoseUnitOfMeasure>
<Text>TABLET</Text>
<Code>C48542</Code>
</Dosage>
<Text>SUBLINGUAL</Text>
<Code>225780003</Code>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Code>258701004</Code>
</IntervalUnits>
</Interval>
<IndicationForUse>
<Text>AS NEEDED FOR</Text>
<Code>420449005</Code>
<Indication>
<Text>CHEST PAIN</Text>
<Code>29857009</Code>
</Indication>
</IndicationForUse>
</Instruction>
<MaximumDoseRestriction>
<MaximumDoseRestrictionNumericValue>3</MaximumDoseRestrictionNumericValue>
<MaximumDoseRestrictionForm>
<Text>TABLET</Text>
<Code>C48542</Code>
</MaximumDoseRestrictionForm>
<MaximumDoseRestrictionDurationValue>15</MaximumDoseRestrictionDurationValue>
<MaximumDoseRestrictionDurationUnit>
<Code>258701004</Code>
</MaximumDoseRestrictionDurationUnit>
<MaximumDoseRestrictionClarifyingFreeText > Or 6 tablets per day</MaximumDoseRestrictionClarifyingFreeText>
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</MaximumDoseRestriction>
</StructuredSIG>
</SIGSample>
1.23.2.49 Use 1 Spray Intranasally In One Nostril, THEN, Repeat 1 Spray Intranasally In Alternating Nostrils Every 2-3 Minues
As Needed. Immediately call 911.
<StructuredSIG>
<SigText>Use 1 spray intranasal in one nostril 1 per day Then repeat 1 spray intranasal in alternating nostrils every 2 to 3 minutes as needed. Immediately call 911</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Use</Text>
<Code>419385005</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>Spray</Text>
<Code>C48537></Code>
</Dosage>
<Text>Intranasal</Text>
<Code>26061700</Code>
<RouteOfAdministrationClarifyingFreeText>in one nostril</RouteOfAdministrationClarifyingFreeText>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
</Instruction>
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<Instruction>
<Text>Repeat</Text>
<Code>27582007</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>Spray</Text>
<Code>C48537></Code>
</Dosage>
<Text>Intranasal</Text>
<Code>26061700</Code>
<RouteOfAdministrationClarifyingFreeText>in atlernating nostrils</RouteOfAdministrationClarifyingFreeText>
<TimingAndDuration>
<Interval>
<IntervalUnits>
<Text>minutes</Text>
<Code>258701004</Code>
</IntervalUnits>
</Interval>
<TimingClarifyingFreeText>as needed</TimingClarifyingFreeText>
</Instruction>
<ClarifyingFreeText>Immediately call 911</ClarifyingFreeText>
</StructuredSIG>
</SIGSample>
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1.24 EXAMPLE 24. PHARMACY REQUESTS CURRENT MEDICATION LIST
In this example, the pharmacy requests that a long term care facility send a list of all current medications for a patient. The facility responds with
the patient’s two current prescriptions, including prescriber information, written dates, and administration end dates.
Transaction
RxHistoryRequest (from Pharmacy to Facility)
RxHistoryResponse (from Facility)
Pharmacy
Field Name Value
<MessageID> 1234567
<RxReferenceNumber>
Facility
<MessageID> 2290
<RxReferenceNumber>
RxHistoryRequest (from Pharmacy to Facility)

Notes:
Element Value Note
To FACILITY123:ZZZ This is the ID of the receiving facility; ZZZ means it is mutually defined
between trading partners.
From 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy. This
is the sender. It must be the pharmacy ID.
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Element Value Note
Gender F Female
STREET:CLYDE:ME:111
22
ServiceTypeCoded C Request criteria: Include only current medications in the response.
Consent Y Patient gave consent for the pharmacy to receive the medication history
from any prescriber.
RxHistoryResponse (from Facility)

Notes:
Element Value Note
From FACILITY123:ZZZ This is the ID of the sending facility; ZZZ means it is mutually defined
MessageID 2290 Facility system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234567 Pharmacy trace number is used to link the (MessageID) from request to
the response.
Approved Approved
Gender F Female
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Element Value Note
STREET:CLYDE:ME:11
122
Consent Y Patient gave consent for the pharmacy to receive the medication history
from any prescriber.
MedicationDispensed
for Tablet Dosage Form”. So this means the prescription is for 4 mg Tablet
dosing form.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology - C28253
LastFillDate 2010-09-15 Last Demand (LastFill): 09/15/2010.
PeriodEnd 2010-10-12 Administration End date: 10/12/2010.
STREET:CLYDE:ME:11
122
DrugDescription METFORMIN HCL Drug prescribed is METFORMIN HCL 850 MG TABLET.
850 MG TABLET
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Element Value Note
StrengthForm C42998 The Source for NCPDP Drug Dosage Form Terminology. C42998 is the code
tablets.
WrittenDate 2010-09-01 Date Written: 09/01/2010.
NumberOfRefills 2 2 refills
Note: Pharmacy information is not included with the medication elements in the example, per section “Structure Quick Reference”
“RxHistoryResponse Transaction”, which states that the pharmacy is not used when the sender of the Medication History Request is a
pharmacy.
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1.25 EXAMPLE 25. EXAMPLES OF NEW PRESCRIPTIONS FOR COMPOUND INGREDIENTS
1.25.1 PRESCRIPTION FOR: AMLODIPINE 1.25MG/ML SUSPENSION
Amlodipine 10 mg. tablets #4
Ora-Plus liquid 16 ml
Ora-Sweet 16 ml
Sig: Take 5 ml orally every 12 hours

This example contains a structured Sig.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
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</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
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<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>Amlodipine 1.25mg/ml Suspension </DrugDescription>
<Quantity>
<Value>32</Value>
<CodeListQualifier>CF</CodeListQualifier>
<Code>C28254</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>Take 5 Milliliter Oral Route EVERY 12 hour</SigText>
<CodeSystem>
</CodeSystem>
<Instruction>
<Text>Take</Text>
<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Text>Milliliter</Text>
<Code>C28254</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Interval>
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<IntervalUnits>
<Text>hour</Text>
<Code>258702006</Code>
</IntervalUnits>
</Interval>
</Instruction>
</Sig>
<CompoundInformation>
<FinalCompoundPharmaceuticalDosageForm>C68992</FinalCompoundPharmaceuticalDosageForm>
<CompoundIngredientsLotNotUsed>
<CompoundIngredient>
<CompoundIngredientItemDescription>AMLODIPINE 10 MG TABLETS</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C48548</Code>
</Strength>
</CompoundIngredient>
<Quantity>
<Value>4</Value>
<Code>C48542</Code>
</Quantity>
</CompoundIngredientsLotNotUsed>
<CompoundIngredientItemDescription>ORA-PLUS</CompoundIngredientItemDescription>
<Quantity>
<Value>16</Value>
<Code>C28254</Code>
</Quantity>
<CompoundIngredientItemDescription>ORA-SWEET</CompoundIngredientItemDescription>
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<Quantity>
<Value>16</Value>
<Code>C28254</Code>
</Quantity>
</CompoundInformation>
</NewRx>
</Body>
</Message>
Notes:
Element Value Note
DrugDescription Amlodipine Drug prescribed DrugDescription is Amlodipine 1.25mg/mL Suspension which
1.25mg/mL is the prescriber’s preferred name for the compound.
Suspension
No other fields are to be sent in the DrugCoded for a compound.
Quantity 32:CF The quantity is 32.
Since this is a compound, this is the final compound quantity. If Compound,
CodeListQualifier must contain “CF” (Compound Final Quantity).
code for “milliliter”.

Sig Structured Sig
When this structured Sig is transformed by the XSLT, the text placed in
<SigText> is TAKE 5 ML BY MOUTH EVERY 12 HOURS
Compound
FinalCompoundPharmace C68992 The Source for NCPDP StrengthForm Terminology- C42992 is the code for
uticalDosageForm “Oral Suspension”.
CompoundIngredientDrug AMLODIPINE 10 MG Compound ingredient drug prescribed is Amlodipine 10mg Tablets.
Description TABLETS First ingredient.
StrengthForm C42998 The Source for NCPDP StrengthForm Terminology- C42998 is the code for
“Tablet”.
the code for “Milligram”. 10 milligrams.
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Element Value Note
CompoundIngredientDrug ORA-PLUS Compound ingredient drug prescribed is Ora-Plus.
Description Second ingredient.
code for “Mililiter”.
CompoundIngredientDrug ORA-SWEET Compound ingredient drug prescribed is Ora-Sweet.
Description Third ingredient.
code for “Mililiter”.
1.25.2 PRESCRIPTION FOR: PROGESTERONE 100MG SR CAPSULES

Progesterone Micro Powder 10 gm
Cellulose Microcrystaline 14 gm
Lactose NF Spray Dried Powder 11.7 gm
Yellow Color 0.02 gm
Rx Quantity #100
Sig: Take one capsule orally daily at bedtime.

This example contains a structured Sig.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
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</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
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</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>PROGESTERONE 100MG SR CAPSULES</DrugDescription>
<Quantity>
<Value>100</Value>
<Code>C48480</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>Take 1 capsule oral route 1 PER day at bedtime</SigText>
<CodeSystem>
<FMTVersion>2012</FMTVersion>
</CodeSystem>
<Instruction>
<Text>Take</Text>
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<Code>419652001</Code>
<Dosage>
<DoseUnitOfMeasure>
<Code>C48480</Code>
</Dosage>
<Code>26643006</Code>
<TimingAndDuration>
<Frequency>
<FrequencyUnits>
<Text>day</Text>
<Code>258703001</Code>
</FrequencyUnits>
</Frequency>
<TimingAndDuration>
<Text>at bedtime</Text>
<Code>396142006</Code>
</Instruction>
</Sig>
<CompoundIngredientItemDescription>PROGESTERONE MICRO POWDER</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42972</Code>
</StrengthForm>
<Code>C48155</Code>
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</Strength>
<Quantity>
<Value>10</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>CELLULOSE MICROCRYSTALLINE</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42901</Code>
</StrengthForm>
<Code>C48155</Code>
</Strength>
<Quantity>
<Value>14</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>LACTOSE NF SPRAY DRIED POWDER</CompoundIngredientItemDescription>
<Strength>
<StrengthValue>11.7</StrengthValue>
<StrengthForm>
<Code>C42972</Code>
</StrengthForm>
<Code>C48155</Code>
</Strength>
<Quantity>
<Value>11.7</Value>
<Code>C48155</Code>
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</Quantity>
<CompoundIngredientItemDescription>YELLOW COLOR</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42953</Code>
</StrengthForm>
<Code>C48155</Code>
</Strength>
<Quantity>
<Value>0.02</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>CAPSULES SIZE 0 WHITE</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C48450</Code>
</StrengthForm>
</Strength>
<Quantity>
<Value>100</Value>
<Code>C25158</Code>
</Quantity>
</NewRx>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
DrugDescription Progesterone 100mg Drug prescribed DrugDescription is Progesterone 100mg SR Capsules which
SR Capsules the prescrber’s preferred name for the compound.
This means dispense 100.
code for “Capsule”.

Sig Structured Sig
When this structured Sig is transformed by the XSLT, the text placed in
<SigText> is TAKE ONE CAPSULE BY MOUTH DAILY AT BEDTIME
Compound
FinalCompoundPharmace C25158 The Source for NCPDP StrengthForm Terminology- C48480 is the code for
uticalDosageForm “Capsule”.
CompoundIngredientDrug PROGESTERONE Compound ingredient drug prescribed is Progesterone Micro Powder.
Description MICRO POWDER First ingredient.
Strength 10 10 is the strength;
StrengthForm C42972 The Source for NCPDP Drug StrengthForm Terminology– C42972 is the code
for “Powder”
the code for “Gram”.
code for “Gram”.
CompoundIngredientDrug CELLULOSE Compound ingredient drug prescribed is Cellulose Microcrystalline.
Description MICROCRYSTALLINE Second ingredient.
StrengthForm C42901 The Source for NCPDP Drug StrenghtForm Terminology- C42901 is the code
for “Crystal”
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Element Value Note
CompoundIngredientDrug LACTOSE NF SPRAY Compound ingredient drug prescribed is Lactose NF Spray Dried Powder.
Description DRIED POWDER Third ingredient.
Strength 11.7 11.7 is the strength
StrengthForm C42972 The Source for NCPDP Drug StrengthForm Terminology– C42972 is the code
for “Powder”
StrengthUnitOfMeasure C48155 the Source for NCPDP Drug StrengthUnitOfMeasure Terminology - C48155 is
CompoundIngredientDrug YELLOW COLOR Compound ingredient drug prescribed is Yellow Color. Fourth ingredient.
Description
StrengthForm C42953 The Source for NCPDP Drug StrengthForm Terminology- C42953 for “Liquid”.
code for “gram”.
CompoundIngredientDrug CAPSULES SIZE 0 Compound ingredient drug prescribed is Capsules size 0 white.
Description WHITE Fifth ingredient.
StrengthForm C25158 The Source for NCPDP Drug Dosage Form Terminology– C25158 is the code
for “Capsule”.
code for “Capsule”.
1.25.3 PRESCRIPTION FOR: MUPIROCIN/BETAMETHASONE/CLOTRIMAZOLE OINTMENT

Mupirocin 2% ointment 22 gm
Betamethasone Valerate 0.1% ointment 22 gm
Clotrimazole 1% cream 22 gm
Sig: Apply sparingly after breast feeding.

This examples contains a textual Sig.
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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
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</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>Mupirocin/Betamethasone/Clotrimazole Ointment</DrugDescription>
<Quantity>
<Value>66</Value>
<Code>C25301</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
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</WrittenDate>
<Sig>
<SigText>APPLY SPARINGLY AFTER BREAST FEEDING</SigText>
</Sig>
<CompoundIngredientItemDescription>MUPIROCIN 2% OINTMENT</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42966</Code>
</StrengthForm>
<Code>C45613</Code>
</Strength>
<Quantity>
<Value>22</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>BETAMETHASONE VALERATE 0.1% OINTMENT</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42966</Code>
</StrengthForm>
<Code>C25613</Code>
</Strength>
<Quantity>
<Value>22</Value>
<Code>C48155</Code>
</Quantity>
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<CompoundIngredientItemDescription>CLOTRIMAZOLE 1% CREAM</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42944</Code>
</StrengthForm>
<Code>C45613</Code>
</Strength>
<Quantity>
<Value>22</Value>
<Code>C48155</Code>
</Quantity>
</NewRx>
</Body>
</Message>
Notes:
Only the pertinent information is included.
Element Value Note
DrugDescription Mupirocin/Betameth Drug prescribed DrugDescription is Mupirocin/Betamethasone/Clotrimazole
asone/Clotrimazole Ointment which the prescrber’s preferred name for the compound.
Ointment No other fields are to be sent in the DrugCoded for a compound.
QuantityUnitOfMeasure C48155 The Source for NCPDP Drug QuantityUnitOfMeasure Terminology - C48155 is

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Element Value Note
SigText APPLY SPARINGLY APPLY SPARINGLY AFTER BREAST FEEDING is the Sig.
AFTER BREAST
FEEDING
Compound
FinalCompoundPharmace C42966 The Source for NCPDP Drug StrengthForm Terminology- C42966 is the code
uticalDosageForm for “Ointment”.
CompoundIngredientDrug MUPIROCIN 2% Compound ingredient drug prescribed is Mupirocin 2% Ointment.
Description OINTMENT First ingredient.
for “Ointment”.
StrengthUnitOfMeasure C25613 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology – C25613 is
the code for “Percentage”.
CompoundIngredientDrug BETAMETHASONE Compound ingredient drug prescribed is Betamethasone Valerate 0.1%
Description VALERATE 0.1% Ointment.
OINTMENT Second ingredient.
for “Ointment”.
StrengthUnitOfMeasure C25613 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology - 25613 is
CompoundIngredientDrug CLOTRIMAZOLE 1% Compound ingredient drug prescribed is Clotrimazole 1% Cream.
Description CREAM Third ingredient.
for “Cream”.
StrengthUnitOfMeasure C25613 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology – C25613 is
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1.25.4 PRESCRIPTION FOR: NIFEDIPINE 0.2% OINTMENT

Nifedipine Powder 0.12 gm
Aquaphor 58.88 gm
Propylene Glycol 1 ml
Sig: Apply to the affected area twice a day

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
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</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
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</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>NIFEDIPINE 0.2% OINTMENT</DrugDescription>
<Quantity>
<Value>66</Value>
<Code>C25301</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
<SigText>APPLY TO THE AFFECTED AREA TWICE A DAY</SigText>
</Sig>
<CompoundIngredientItemDescription>NIFEDIPINE POWDER</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42972</Code>
</StrengthForm>
<Code>C48155</Code>
</Strength>
<Quantity>
<Value>0.12</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>AQUAPHOR</CompoundIngredientItemDescription>
<Strength>
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<StrengthForm>
<Code>C42966</Code>
</StrengthForm>
<Code>C48155</Code>
</Strength>
<Quantity>
<Value>58.88</Value>
<Code>C48155</Code>
</Quantity>
<CompoundIngredientItemDescription>PROPYLENE GLYCOL</CompoundIngredientItemDescription>
<Strength>
<StrengthForm>
<Code>C42953</Code>
</StrengthForm>
<Code>C28254</Code>
</Strength>
<Quantity>
<Value>1</Value>
<Code>C28254</Code>
</Quantity>
</NewRx>
</Body>
</Message>
Notes:
Only the pertinent information is included.
Element Value Note
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Element Value Note
DrugDescription Nifedipine 0.2% Drug prescribed DrugDescription is Nifedipine 0.2% Ointment which is the
Ointment prescribers preferred name for the compound.
CodeListQualifier must contain “CF” (Compound Final Quantity)..

SigText APPLY TO THE APPLY TO THE AFFECTED AREA TWICE A DAY is the Sig.
AFFECTED AREA
TWICE A DAY
Compound
FinalCompoundPharmaceut C42966 The Source for NCPDP StrengthForm Terminology- C42966 is the code for
icalDosageForm “Ointment”.
CompoundIngredientDrugD NIFEDIPINE POWDER Compound ingredient drug prescribed is Nifedipine Powder.
escription First ingredient.
Strength 0.12 12 is the strength
StrengthForm C42972 The Source for NCPDP StrenghtForm Terminology– C42972 is the code for
“Powder”
CompoundIngredientDrugD AQUAPHOR Compound ingredient drug prescribed is Aquaphor Ointment.
escription OINTMENT Second ingredient.
StrengthForm C42966 The Source for NCPDP StrenghtForm Terminology- C42966 is the code for
“Ointment”.
CompoundIngredientDrugD PROPYLENE GLYCOL Compound ingredient drug prescribed is Propylene Glycol.
escription Third ingredient.
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Element Value Note
StrengthForm C42953 The Source for NCPDP StrengthForm Terminology- C42953 is the code for
“Liquid”
the code for “Milliliter”.
code for “milliliter”.
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1.26 EXAMPLE 26. PRESCRIBER SUSPENDS MEDICATION ADMINISTRATION FOR A CLINICAL REASON, THEN
RESUMES (DIRECT CONNECT)
In this example, the physician prescribes a medication in an environment where the pharmacy operates under protocol to maintain a supply of
the prescribed medication at the point of care. The original order uses the Quantity Sufficient convention for populating the quantity
elements—directing the pharmacy to employ the predetermined protocol.
After the order becomes active, the physician suspends administration of the drug due to a clinical reason. This is communicated in an
DrugAdministration transaction, using <IndefiniteSuspension>.
Lastly, the prescriber resumes administration of the medication and sends another DrugAdministration transaction containing the
<ResumeAdministration>
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IndefiniteSuspension
(1) DrugAdministration contains only the

suspend start date/time
DrugAdministration - IndefiniteSuspension
Status
Prescriber
Pharmacy
(2) DrugAdministration contains the resume
date/time
DrugAdministration - ResumeAdministration
Status
DrugAdministration DrugAdministration
(indefinite) from (resume) from Prescriber
NewRx from Prescriber Prescriber
<MessageID> 1234567 1234569 1234572
<RxReferenceNumber>
Status from Pharmacy Status from Pharmacy Status from Pharmacy
<MessageID> ABC11 ABC52 ABC88
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<RxReferenceNumber>
Original Prescription
Transaction
Notes:
Element Value Note
From 77777777:D This is the Prescriber ID of the sender; D means it is a Prescriber.
SecondaryIdentification PASSWORDQ Password of the Prescriber directly to the Pharmacy, if used, depending on
SentTIme 2010-10-01T08:15:22 Date and time transaction was sent 10/01/2010 08:15:22 AM
Gender F Female
SW:CLANCY:WI:54999, US
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Element Value Note
ROAD:JONESVILLE:TN:37777
, US
NPI 9876543210 This is the NPI of the sending facility.
FacilityName GOLDEN OAKS Name of Facility
CommunicationNumber 6152201234 Phone Number of Facility (615) 220-1234.
tablets.
Quantity 0:QS This directs the pharmacy to dispense the quantity sufficient under the
protocol in place with the provider.

SigText TAKE ONE TABLET TWO TAKE ONE TABLET… is the Sig.
TIMES A DAY UNTIL GONE
Prescriber suspends administration of the drug

DrugAdministration Suspend Message (from Prescriber)
Transaction
DrugAdministration (from Prescriber)
DrugAdministration Suspend Message (from Prescriber)

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<Header>
<From Qualifier="D">77777777</From>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<DrugAdministration>
<Facility>
<Identification>
<NPI>9876543210</NPI>
</Identification>
<FacilityName>GOLDEN OAKS</FacilityName>
<PrimaryTelephone>
</PrimaryTelephone>
</Facility>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
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<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugAdministrationRequest>
<IndefiniteSuspension>
<SuspendDateTime>2010-10-01T09:30:47Z</SuspendDateTime>
<TimeZone>
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<TimeZoneIdentifier>UT</TimeZoneIdentifier>
<TimeZoneDifferenceQuantity>-0600</TimeZoneDifferenceQuantity>
</TimeZone>
</IndefiniteSuspension>
<DrugAdminReasonCode>01</DrugAdminReasonCode>
<DrugAdminReasonText>SUSPEND PENDING EXAMINATION</DrugAdminReasonText>
</DrugAdministrationRequest>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>0</Value>
<CodeListQualifier>QS</CodeListQualifier>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</DrugAdministration>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
SentTIme 2010-10-01T08:15:22 Date and time transaction was sent 10/01/2010 08:15:22 AM
PrescriberOrderNumber 110088 This is the reference number assigned by the prescribing system. This
identifies the medication that’s being suspended.
DrugAdministration DrugAdministration The transaction type: Drug Administration.
IndefiniteSuspension Indicates that administration of the prescription has been suspended
indefinitely.
SuspendDateTime 2010-10-01T09:30:47Z Suspend date/time 2010-10-01 09:30:47 A.M.
TimeZone UT:-0600 Time Zone. UT is the time zone method (Universal Time), and -6000 adjusts
the zone six hours back from Greenwich Mean Time, which equates to
Central Time.
DrugAdminReasonCode 03 Reason code: 03 = Other clinical reason
DrugAdminReasonText SUSPEND PENDING Additional textual reason for suspending administration: “Suspend pending
EXAMINATION examination”
Gender F Female
and Qualifier
777
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Element Value Note

TIMES A DAY UNTIL
GONE
Prescriber resumes administration of the drug

DrugAdministration Resume message (from Prescriber)
Transaction
DrugAdministration (from Prescriber)
A day later
DRUADM Resume message (from Prescriber)

<Header>
<From Qualifier="D">77777777</From>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<DrugAdministration>
<Facility>
<Identification>
<NPI>9876543210</NPI>
</Identification>
<FacilityName>GOLDEN OAKS</FacilityName>
<PrimaryTelephone>
</PrimaryTelephone>
</Facility>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
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<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugAdministrationRequest>
<ResumeAdministration>
<ResumeDateTime>2010-10-02T09:30:47Z</ResumeDateTime>
<TimeZone>
<TimeZoneIdentifier>UT</TimeZoneIdentifier>
<TimeZoneDifferenceQuantity>-0600</TimeZoneDifferenceQuantity>
</TimeZone>
</ResumeAdministration>
</DrugAdministrationRequest>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
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</DrugCoded>
<Quantity>
<Value>0</Value>
<CodeListQualifier>QS</CodeListQualifier>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</DrugAdministration>
</Body>
</Message>
Notes:
Element Value Note
SentTIme 2010-10-02T08:15:22 Date and time message was sent 10/02/2010 08:15:22 AM
PrescriberOrderNumber 110088 This is the reference number assigned by the prescribing system. This
identifies the medication that’s being resumed.
DrugAdministration DrugAdministration The transaction type: Drug Administration.
ResumeAdministration Indicates that administration of the prescription has been resumed.
ResumeDateTIme 2010-10-02T09:30:47Z Resume date/time 10/02/2010 09:30:47 is the resume date/time
TimeZone UT:-0600 Time Zone. UT is the time zone method (Universal Time), and -6000 adjusts
the zone six hours back from Greenwich Mean Time, which equates to
Central Time.
Gender F Female
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Element Value Note
777

TIMES A DAY UNTIL
GONE
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1.27 EXAMPLE 27. PHARMACY REQUESTS MEDICATION HISTORY WITH HISTORYSOURCE
ELEMENT FROM A PRESCRIBER (DIRECT CONNECT)
In this example, the pharmacy is requesting dispensed and/or administered medications for a patient between the date range of 01/01/2010
and 12/01/2010 from a prescriber. There are three occurrences that are known to the prescriber. Per the rules in Section “Specific Element
Discussion”, subsection “Source Element”, the <Pharmacy> and specific pharmacy identification in the <Source> is not allowed to be returned in
the Medication History response when the requester is a pharmacy. This example incorporates the two sample scenarios as described below.
Scenario1
Patient presents themselves at the pharmacy for refill of a sample that was given to them by the prescriber. Pharmacy submits a medication
history request to the prescriber and receives a medication history response that lists all medications/vaccines that the prescriber administered
or dispensed to the patient.
Scenario2
Patient brings in a new prescription, and asks the pharmacist if this new medication will interact with something the doctor gave them in the
office. Pharmacy submits a medication history request to the prescriber and receives a medication history response that lists all
medications/vaccines that the prescriber administered or dispensed to the patient. Pharmacist runs DUR checks against the items returned in
the response.
Transaction
RxHistoryResponse (from Prescriber)
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Pharmacy
Field Name Value
<MessageID> A112
<RxReferenceNumber>
Prescriber
<MessageID> X222
<RelatesToMessageID> A112
<RxReferenceNumber>

Notes:
Element Value Note
sender.
SecondaryIdentification PASSWORD5 This is the password of the pharmacy on the prescriber’s system.
01T08:13:22
SenderSoftwareDeveloper ACE Sender Software Developer: ACE SOFTWARE
, SenderSoftwareProduct, SOFTWARE:ACE1:1.1 Sender Software Product: ACE1
ease
Gender F Female
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Element Value Note
STREET:CLYDE:ME:1
1122
First Name
Consent Y Patient gave consent for the pharmacy to receive the medication history from
any prescriber.
RxHistoryResponse (from Prescriber)

Notes:
Element Value Note
To 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy.
This is the receiver.
From 77777777:C This is the ID of the sender; C means it is a Clinic.
MessageID X222 Prescriber system trace number for the transmission. Echoed back
in the response transaction in RelatesToMessageID.
RelatesToMessageID A112 Pharmacy trace number is used to link the (MessageID) from
SecondaryIdentification PASSWORDQ This is the password of the clinic on the pharmacy’s system.
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Element Value Note
SenderSoftwareDeveloper MD80SYSTEM:80:15.2 Sender Software Developer: MD80SYSTEM
, SenderSoftwareProduct, Sender Software Product: 80
ease
Approved Approved
Gender F Female
STREET:CLYDE:ME:11122
First Name
EffectiveDate 2009-01-01 Effective Date (Begin) is 01/01/2009.
ExpirationDate 2009-12-01 Expiration Date is 12/01/2009.
Consent Y Patient gave consent for prescriber to receive the medication
history from any prescriber.
PBMMemberID MEMBERID The Patient Identifier returned from the payer.
MedicationDispensed
StrengthForm C48542 The Source for NCPDP Drug Dosage Form Terminology- C48542 is
the code for “Tablet dosing form”. So this means the prescription is
for 4 mg Tablet dosing form.
StrengthUnitOfMeasure C28253 The Source for NCPDP Drug StrengthUnitOfMeasure Terminology -
C28253 is the code for “Milligram”.
QuantityUnitOfMeasure C48542 The Source for NCPDP QuantityUnitOfMeasure Terminology-
C48542 is the code for “Tablet”.
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Element Value Note
Substitutions 0 0 is No Product Selection Indicated, which means substitution is
allowed.
HistorySource PC Source Qualifier of Prescriber (PC).
SourceQualifier
SourceDescription TIM JONSON
Reference ID Value and 3334444:0B Reference Number of the Source Description – Prescriber State
Qualifier Identification Number (0B)
Prescriber Information about the prescriber for the medication MEDROL
DOSEPACK.
MedicationDispensedAdmi
nistered
DrugDescription FLUVIRIN INJ 2009 FLUVIRIN INJ 2009 is the drug dispensed and administered.
Qualifier
StrengthForm C42946 The Source for NCPDP Drug Dosage Form Terminology-
C42946 is the code for “Injectable Dosage Form”
QuantityUnitOfMeasure C28254 The Source for NCPDP QuantityUnitOfMeasure Terminology-
C28254 is the code for “milliliter”.
Substitutions 0 0 is No Product Selection Indicated, which means substitution is
allowed.
RefillsRemaining REM:0 No refills remaining
HistorySource PC Source Qualifier of Prescriber (PC).
SourceQualifier
SourceDescription TIM JONSON
Reference ID Value and 3334444:0B Reference Number of the Source Description – Prescriber State
Qualifier Identification Number (0B)
Prescriber PC Information about the prescriber for the medication FLUVIRIN.
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1.28 EXAMPLE 28. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG KNOWN) FROM PHARMACY
TO PRESCRIBER (DIRECT CONNECT)
In this example the pharmacy has identified a situation for a new prescription during patient counseling. Patient has diabetes and has an ACE
Inhibitor gap in therapy. Based on patient's plan coverage, Lisinopril is the preferred product. The pharmacy requests the prescriber issue a
prescription for Lisinopril to close this gap.
The pharmacy sends a new prescription request to a prescriber. It is assumed that there is a direct connection (dedicated line) between the
pharmacy and the prescriber. After the prescriber evaluates the request and approves, the prescriber system sends a new prescription
transaction to the pharmacy.
Transaction
NewRxRequest (from Pharmacy)
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NewRxRequest from NewRx from Prescriber
Pharmacy
<MessageID> 12345678901234567890 AA77
<RxReferenceNumber>
<MessageID> 66666691 XX558995

<RelatesToMessageID> 12345678901234567890 AA77
<RxReferenceNumber>

<Header>
<SentTime>2010-12-17T14:17:52Z</SentTime>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
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<NewRxRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
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</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>LISINOPRIL 10 MG TABLET</DrugDescription>
<DrugCoded>
<ProductCode>
<Code>00591040701</Code>
</ProductCode>
</DrugCoded>
<Diagnosis>
<ClinicalInformationQualifier>1</ClinicalInformationQualifier>
<Primary>
<Code>2508</Code>
<Qualifier>DX</Qualifier>
<Description>Diabetes with other specified manifestations</Description>
</Primary>
</Diagnosis>
<Note>Patient has diabetes and has an ACE Inhibitor gap in therapy. Based on patient's benefit, Lisinopril is the preferred product. Please issue a prescription for Lisinopril to close this gap.</Note>
</NewRxRequest>
</Body>
</Message>
Notes:
Element Value Note
From 7701630:P NCPDP Provider ID Number of pharmacy; P means it is a pharmacy.
This is the sender. It must be the pharmacy ID.
890 response transaction in RelatesToMessageID.
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Element Value Note
RelatesToMessageID) Not sent. Not applicable.
SecondaryIdentification PASSWORD5 Password of the Payer directly to the Pharmacy, if used, depending on trading
partner agreements.
NewRxRequest NewRxRequest The transaction type: NewRxRequest.
Gender F Female
NCPDP ID 7701630 This is the NCPDP ID of the pharmacy.
StoreName MAIN STREET Name of pharmacy.
PHARMACY
Address 5400 S 121 ST, Address of pharmacy.
HALES CORNERS, TN,
37122, US
Communication Number 6152205656 Phone Number of Pharmacy (615) 220-5656.
ROAD:JONESVILLE:T
N:37777, US
DrugDescription LISINOPRIL 10 MG Lininopril 10mg tablet
TABLET
ProductCode 00591040701:ND (optional NDC) ND is the qualifier for NDC
ClinicalInformationQualifier 1 Prescriber/Prescriber Supplied – The diagnosis was given or supplied by the
prescriber.
PrimaryDiagnosis DX:2508 ICD-9-CM diagnosis of 2508 Diabetes with other specified manifestations
Note Patient has diabetes Information provided in explanation.
and has an ACE
Inhibitor gap in
therapy. Based on
patient's benefit,
Lisinopril is the
preferred product.
Please issue a
prescription for
Lisinopril to close
this gap
The Prescriber system sends back a Status.
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<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P Pharmacy ID. Now the destination.
MessageID 66666691 Trace number for this transmission.
RelatesToMessageID 123456789012345678 Pharmacy trace number is used to link the original transaction (value in
90 MessageID) from request to the response.
The Prescriber then sends the new prescription (see any example above of a new prescription). The NewRx <RelatesToMessageID> must contain
the <MessageID> from the NewRxRequest.
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1.29 EXAMPLE 29. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG UNKNOWN) FROM
PHARMACY TO PRESCRIBER (DIRECT CONNECT)
This example is similar to the example above, except in this case the patient has relayed the kind of medication, but the specifics are unknown.
pharmacy and the prescriber. After the prescriber evaluates the request, the prescriber system sends a new prescription transaction to the
pharmacy.
Transaction

Pharmacy
<MessageID> 12345678901234567890 AA799
<RxReferenceNumber>
<MessageID> 66666691 XX558995

<RxReferenceNumber>

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRxRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
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<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>Diabetes Medication</DrugDescription>
<Diagnosis>
<Primary>
<Code>250</Code>
<Description>Diabetes mellitus</Description>
</Primary>
</Diagnosis>
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<Note>Patient indicates that the prescriber was supposed to send our pharmacy a prescription for Diabetes. Patient is unsure of name of drug. Please send a NewRx.</Note>
</NewRxRequest>
</Body>
</Message>
Notes:
Element Value Note
partner agreements.
Gender F Female
PHARMACY
HALES CORNERS, TN,
37122, US
ROAD:JONESVILLE:T
N:37777, US
DrugDescription Diabetes Medication Type of medication information from the patient.
prescriber.
PrimaryDiagnosis DX: 25 ICD-9-CM diagnosis of 250 Diabetes Mellitus
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Element Value Note
Note Patient indicates Information provided in explanation.
that the prescriber
was supposed to
send our pharmacy a
prescription for
Diabetes. Patient is
unsure of name of
drug. Please send a
NewRx
The Prescriber system sends back a Status transaction.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
The Prescriber then sends the new prescription (see any example above of a new prescription). The NewRx <RelatesToMessageID> must contain
the <MessageID> from the NewRxRequest.
1.30 EXAMPLE 30. NEWRXREQUEST APPROVED FOR NEW PRESCRIPTION (DRUG CLASS) FROM PHARMACY TO
PRESCRIBER (DIRECT CONNECT)
This example is similar to the example above, except in this case the patient has relayed the kind of medication, but the specifics are unknown
and the pharmacist has determined the drug class.
pharmacy and the prescriber. After the prescriber evaluates the request, the prescriber system sends a new prescription transaction to the
pharmacy.
Transaction
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Pharmacy
<MessageID> 12345678901234567890 AA99
<RxReferenceNumber>
<MessageID> 66666691 XX558995

<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
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<NewRxRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
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</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>ACE Inhibitor</DrugDescription>
<DrugCoded>
<DrugDBCode>
<Code>240802</Code>
<Qualifier>AF</Qualifier>
</DrugDBCode>
</DrugCoded>
<Note>Patient has diabetes and has an ACE Inhibitor gap in therapy. Please prescribe an ACE Inhibitor to close this gap.</Note>
</NewRxRequest>
</Body>
</Message>
Notes:
Element Value Note
partner agreements.
Gender F Female
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Element Value Note
PHARMACY
HALES CORNERS, TN,
37122, US
ROAD:JONESVILLE:T
N:37777, US
DrugDescription ACE Inhibitor Type of medication information requested.
DrugDBCode AF: 240802 American Hospital Formulary Service (AHFS) code and qualifier.
Note Patient has diabetes Information provided in explanation.
and has an ACE
Inhibitor gap in
therapy. Please
prescribe an ACE
Inhibitor to close this
gap.
The Prescriber system sends back a Status transaction.

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
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<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
The Prescriber then sends the new prescription (see any example above of a new prescription).
The NewRx <RelatesToMessageID> must contain the <MessageID> from the NewRxRequest.
1.31 EXAMPLE 31. NEWRXREQUEST DENIED FOR NEW PRESCRIPTION (DRUG CLASS) FROM PHARMACY TO
PRESCRIBER (DIRECT CONNECT)
This example shows a denied response to Example 28 above.
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pharmacy and the prescriber. The prescriber denies the request for a new prescription and requests follow up action.
Transaction
NewRxResponseDenied (from Prescriber)
NewRxRequest from NewRxResponseDenied

Pharmacy from Prescriber
<MessageID> 12345678901234567890 AA99
<RxReferenceNumber>
<MessageID> 66666691 XX558995

<RxReferenceNumber>
See example 28 above.
The Prescriber evaluates, then sends a denial of the new prescription.
NewRxResponseDenied (from Prescriber)

<Header>
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<MessageID>AA99</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRxResponseDenied>
<Response>
<ReasonCode>AF</ReasonCode>
<DenialReason>Patient must make an appointment to be evaluated first</DenialReason>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
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</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>Diabetes Medication</DrugDescription>
<Diagnosis>
<Primary>
<Code>250</Code>
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<Description>Diabetes mellitus</Description>
</Primary>
</Diagnosis>
</NewRxResponseDenied>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P This is the NCPDP Provider ID Number of pharmacy of the receiver; P
means it is a pharmacy.
From 77777777:C Clinic ID This is the sender. C means it is a Clinic.
MessageID AA99 Clinic system trace number for the transmission. Echoed back in the
RelatesToMessageID) 12345678901234567 Pharmacy trace number is used to link the original transaction (value in
SecondaryIdentification PASSWORDQ Password of the Payer directly to the Pharmacy, if used, depending on trading
partner agreements.
NewRxResponseDenied NewRxResponseDeni The transaction type: NewRxResponseDenied
ed
Gender F Female
PHARMACY
HALES CORNERS, TN,
37122, US
ROAD:JONESVILLE:T
N:37777, US
DrugDescription Diabetes Medication Type of medication information from the patient.
prescriber.
PrimaryDiagnosis DX: 250 ICD-9-CM diagnosis of 250 Diabetes Mellitus
Denied AF ReasonCode - Patient should contact Provider first.
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Element Value Note
Patient must make Additional information.
an appointment to
be evaluated first
1.32 EXAMPLE 32. PRIOR AUTHORIZATION NOT REQUIRED

In this example the prescriber system submits a PAInitiationRequest to a payer and receives a Status response. The payer system evaluates the
prior authorization request and returns a PAInitiationResponse indicating that prior authorization is not required for the specified patient and
prescription. The prescriber system replies with a Status response.
Transaction
PAInitiationRequest (from Prescriber)
Status (from Payer)
PAInitiationResponse (from Payer)
Status (From Prescriber)
PAInitiationRequest
Status
Prescriber
Payer
After elapsed time
PAInitiationResponse
Status
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<PAReferenceID> is 22AAB
PAInitiationRequest from PAInitiationResponse

Prescriber from Payer
Field Name Value
<MessageID> 1234567 X53
<RxReferenceNumber>
<PAReferenceID> 22AAB 22AAB
<PACaseID> A101
Status from Payer Status from Prescriber
<MessageID> 8888 95
<RelatesToMessageID> 1234567 X53
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<PAInitiationRequest>
<PAReferenceID>22AAB</PAReferenceID>
<PBMMemberID>333445555</PBMMemberID>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
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</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
</PAInitiationRequest>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
To PAYER123:ZZZ This is the ID of the receiving payer; ZZZ means it is mutually defined
PAInitiationRequest PAInitiationRequest The transaction type: PA Initiation Request.
ase
PAReferenceID 22AAB Assigned by the prescribing system on the initial transaction and is used as
a tracking identifier on all request and response transactions to tieback
related prior authorization transactions.
PBMMemberID 333445555 Payer-assigned member ID for the patient
Gender F Female
CLANCY, WI, 54999
JONESVILLE, TN, 37777
tablets.
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Element Value Note

TIMES A DAY UNTIL
GONE
Status (from Payer)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

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<Header>
<MessageID>X53</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAInitiationResponse>
<PAReferenceID>22AAB</PAReferenceID>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
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<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
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<Code>C48542</Code>
</Quantity>
<Sig>
<SigText>TAKE 1 TABLET BY MOUTH EVERY MORNING</SigText> </Sig>
<Response>
<ResponseStatus>
<Closed>
<PACaseID>A101</PACaseID>
<ReasonCode>CC</ReasonCode>
<PANote>Requested quantity is within the covered limit. Prior authorization is not required.</PANote>
</Closed>
</ResponseStatus>
</Response>
</PAInitiationResponse>
</Body>
</Message>
Notes:
Element Value Note
From PAYER123:ZZZ This is the ID of the sending payer; ZZZ means it is mutually defined
MessageID X53 Payer system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234567 Message ID from the PAInitiationRequest.
PAInitiationResponse PAInitiationResponse The transaction type: PA Initiation Response.
SenderSoftwareDeveloper, MD80SYSTEM:80:15.2 Sender Software Developer: MD80SYSTEM
ase
PAReferenceID 22AAB Assigned by the prescribing system on the initial transaction and is used as
a tracking identifier on all request and response prior authorization
transactions to tieback related prior authorization transactions.
Gender F Female
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Element Value Note
CLANCY, WI, 54999
tablets.

TIMES A DAY UNTIL
GONE
Response
PACaseID A101 Payer-assigned identifier for this request.
ResponseStatus Closed Because prior authorization is not required for the submitted case, no
further PA messages will be exchanged.
ReasonCode CC Prior Authorization not required for patient/medication
Note Requested quantity is Additional information related to the Payer’s response.
within the covered limit.
Prior authorization is
not required.

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<Header>
<RelatesToMessageID>X53</RelatesToMessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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1.33 EXAMPLE 33. PRIOR AUTHORIZATION INITIATION, REQUEST AND APPROVAL
In this example the prescriber system submits a PAInitiationRequest to a Payer and receives a Status response. The Payer then returns a
PAInitiationResponse including a question set indicating the information needed for the approval process. The prescriber system replies with a
Status response followed by a PARequest containing the completed question set. The Payer returns a Status response and then completes the
PA process by sending a PAResponse containing approval. The prescriber system receives the approval and returns a Status response.
The requested medication is Lovenox (Lovenox 40 MG Per 0.4 ML Prefilled Syringe; RxNorm SBD 854236; NDC 58016487201).
The prior authorization questions to be completed by the prescriber are:
1. Is this patient home self-administering? (Y/N)
2. Is the medication to be used to treat prophylaxis? (Y/N)
3. [IF YES] When was or will the surgery be done? (Date without time portion)
[Continue question #6]
4. Is the medication to be used for treatment of DVT? (Y/N)
5. [IF YES] What is the patient’s current weight (in pounds)? (Numeric)
6. Describe result of Warfarin use (include INR and date drawn) or reason why patient can’t use Warfarin. (Free text)
Transaction
Status (from Payer)
PARequest (from Prescriber)
Status (from Payer)
PAResponse (from Payer)
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PAInitiationRequest
Status
After elapsed time
Status
Prescriber
Payer
After elapsed time
PARequest
Status
After elapsed time
PAResponse
Status
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<PAReferenceID> is 77XX2
PAInitiationRequest from PAInitiationResponse PARequest from PAResponse from Payer

Prescriber from Payer Prescriber
<MessageID> 1234567 X53 1234569 8890
<RelatesToMessageID> 1234567 X53 1234569
<RxReferenceNumber>
<PAReferenceID> 77XX2 77XX2 77XX2 77XX2
<PACaseID> A101 A101 A101
Status from Payer Status from Prescriber Status from Payer Status from Prescriber
<MessageID> 8888 95 9XX 1234570

<RelatesToMessageID> 1234567 X53 1234569 8890
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<PAReferenceID>77XX2</PAReferenceID>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
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</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<Code>C42576</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>12</Value>
<Code>C78746</Code>
</Quantity>
<Sig>
<SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText> </Sig>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
ase
PAReferenceID 77XX2 Assigned by the prescribing system on the initial transaction and is used as
Gender F Female
CLANCY, WI, 54999
DrugDescription LOVENOX 40 MG PER Drug prescribed is Lovenox 40 MG per 0.4 ML Prefilled Syringe.
0.4 ML PREFILLED
SYRINGE
StrengthForm C42945 C42945 is the code for “injectable solution”.
StrengthUnitOfMeasure C42576 C42576 is the code for used for “milligrams per milliliter”.
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Element Value Note
QuantityUnitOfMeasure C78746 C78746 is the code for “Mililiter”.

SigText INJECT 40 MG INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY …. is the Sig.
SUBCUTANEOUSLY
ONCE DAILY
Status (from Payer)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
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<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<Code>C42576</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>12</Value>
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<Code>C78746</Code>
</Quantity>
<Sig>
<SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText> </Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
<DateTime>2014-10-01T23:59:59</DateTime>
</DeadlineForReply>
<QuestionSet>
<Header>
<QuestionSetID>QS101</QuestionSetID>
<QuestionSetTitle>Lovenox PA Form</QuestionSetTitle>
<QuestionSetDescription>Please provide all information requested. Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient
information.</QuestionSetDescription>
<QuestionSetContactCommunicationNumber>
<PrimaryTelephone>
</PrimaryTelephone>
</QuestionSetContactCommunicationNumber>
<AttachementRequired>N</AttachementRequired>
</Header>
<Question>
<QuestionID>Q1</QuestionID>
<SequenceNumber>1</SequenceNumber>
<QuestionText>Is this patient home self-administering?</QuestionText>
<DefaultNextQuestionID>Q2</DefaultNextQuestionID>
<QuestionType>
<Select>
<SelectMultiple>N</SelectMultiple>
<Choice>
<ChoiceID>Q1C1</ChoiceID>
<ChoiceText>Yes</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
</Choice>
<Choice>
<ChoiceText>No</ChoiceText>
</Choice>
</Select>
</QuestionType>
</Question>
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<Question>
<QuestionText>Is the medication to be used to treat prophylaxis?</QuestionText>
<QuestionType>
<Select>
<Choice>
<NextQuestionID>Q3</NextQuestionID>
</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionText>When was or will the surgery be done?</QuestionText>
<QuestionType>
<Date>
<IsDateTimeRequired>N</IsDateTimeRequired>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionText>Is the medication to be used for treatment of DVT?</QuestionText>
<QuestionType>
<Select>
<Choice>
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</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionText>What is the patient's weight (in pounds)?</QuestionText>
<QuestionType>
<Numeric>
<IsNumeric>Y</IsNumeric>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionText>Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin.</QuestionText>
<DefaultNextQuestionID>END</DefaultNextQuestionID>
<QuestionType>
<FreeText>
<IsFreeText>Y</IsFreeText>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
ase
Gender F Female
CLANCY, WI, 54999
0.4 ML PREFILLED
SYRINGE
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Element Value Note
SUBCUTANEOUSLY
ONCE DAILY
ResponseStatus Open
DeadlineForReply 2014-10-01T23:59:59 Deadline for responding to this case in datetime format
QuestionSet
QuestionSet A question set is included in the Payer’s response.
Header
QuestionSetID QS101 Payer-assigned ID for this question set.
QuestionSetTitle Lovenox PA Form The title of the question set, “Lovenox PA Form” can be presented to the
end-user.
QuestionSetDescription Please provide all Instructions for the end-user.
information requested.
Failure to complete this
form in its entirety may
result in delayed
processing or an
adverse determination
for insufficient
information.
QuestionSetContactPhoneN 5555551212 Contact phone number at the Payer for questions related to this PA
umber process.
Question 1
Question
QuestionID Q1 Payer-assigned ID for this question.
QuestionText Is this patient home Question text to be displayed to the end-user.
self-administering?
SequenceNumber 1 Order of this question relative to other questions in this question set.
DefaultNextQuestionID Q2 Next question to display regardless of the answer to this question.
Select The type of this question is Select
SelectMultiple N Only one answer may be returned for this question (No)
Choice First choice
ChoiceID Q1C1 Payer-assigned ID for this choice
ChoiceText Yes Text to be presented to the end-user
SequenceNumber 1 Order of this choice relative to other choices for this question.
AdditionalFreeTextIndicator NA No additional free text is allowed when selecting this choice.
Choice Second choice
ChoiceText No Text to be presented to the end-user
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Element Value Note
Question 2
Question
QuestionText Is the medication to be Question text to be displayed to the end-user.
used to treat
prophylaxis?
Choice First choice
NextQuestionID Q3 Next question to be answered if this choice is selected.
Question 3 Conditional question to be asked if Question 2 answer is Yes
Question
QuestionText When was or will the Question text to be displayed to the end-user.
surgery be done?
Date The type of this question is Date
IsDateTimeRequired N Time information is not required in the response to this question. (No)
Question 4
Question
used for treatment of
DVT?
Choice First choice
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Element Value Note
Question 5 Conditional question to be asked if previous question’s answer is Yes
Question
QuestionText What is the patient’s Question text to be displayed to the end-user.
current weight (in
pounds)?
IsNumeric Y The type of this question is Numeric.
Question 6
Question
QuestionText Describe result of Question text to be displayed to the end-user.
Warfarin use (include
INR and date drawn) or
reason why patient
can’t use Warfarin.
DefaultNextQuestionID END This is the last question in the question set..
IsFreeText Y Indicates this is a free text question (Yes)

<Header>
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<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
The trace number <MessageID> assigned by the prescribing system when they sent the PAInitiationRequest was X53.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
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<Body>
<PARequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
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</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<Code>C42576</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>12</Value>
<Code>C78746</Code>
</Quantity>
<Sig>
<SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText>
</Sig>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
<QuestionSetTitle>Lovenox PA Form</QuestionSetTitle>
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<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionText>Is this patient home self-administering?</QuestionText>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
<Answer>
<PrescriberProvidedAnswer>
</PrescriberProvidedAnswer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionText>Is the medication to be used to treat prophylaxis?</QuestionText>
<QuestionType>
<Select>
<Choice>
</Choice>
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<Choice>
</Choice>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Date>
<Date>
</Date>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
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</Choice>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Numeric>
<Answer>
<PrescriberProvidedNumericAnswer>164</PrescriberProvidedNumericAnswer>
</Answer>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionType>
<FreeText>
<Answer>
<PrescriberProvidedAnswer>Patient has an allergy to Warfarin</PrescriberProvidedAnswer>
</Answer>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</PARequest>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
RelatesToMessageID X53 Prescriber trace number is used to link the original transaction
(PAInitationResponse) (MessageID) to this subsequent transaction.
PARequest PARequest The transaction type: PA Request.
ase
Gender F Female
CLANCY, WI, 54999
0.4 ML PREFILLED
SYRINGE
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Element Value Note

SUBCUTANEOUSLY
ONCE DAILY
Request
SolicitedModel SolicitedModel
DeadlineForReply 2014-10-01T23:59:59 Deadline for response (echoed from PAInitiationResponse)
QuestionSet
Header
QuestionSetTitle Lovenox PA Form The title of the question set, “Lovenox PA Form” can be presented to the
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
QuestionText Is this patient home Question text to be displayed to the end-user.
self-administering?
Choice First choice
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Element Value Note
Answer
PrescriberProvidedAnswer
ChoiceID Q1C1 ChoiceID associated with the selected choice.
Question 2
Question
used to treat
prophylaxis?
Choice First choice
Answer
Question 3 Conditional question to be asked if Question 2 answer is Yes
Question
QuestionText When was or will the Question text to be displayed to the end-user.
surgery be done?
Date The type of this question is Date
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Element Value Note
IsDateTimeRequired N Time information is not required in the response to this question. (No)
NOTE: This question was not answered based on the NextQuestionID of the previously selected answer.
Question 4
Question
used for treatment of
DVT?
Choice First choice
Answer
Question 5 Conditional question to be asked if previous question’s answer is Yes
Question
QuestionText What is the patient’s Question text to be displayed to the end-user.
current weight (in
pounds)?
IsNumeric The type of this question is Numeric
Answer
PrescriberProvidedAnswer 164
Question 6
Question
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Element Value Note
QuestionText Describe result of Question text to be displayed to the end-user.
Warfarin use (include
INR and date drawn) or
reason why patient
can’t use Warfarin.
DefaultNextQuestionID END This is the last question in the question set..
Answer
PrescriberProvidedAnswer Patient has an allergy
to Warfarin
Status (from Payer)

<Header>
<MessageID>9XX</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
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</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<Code>C42576</Code>
</Strength>
</DrugCoded>
<Quantity>
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<Value>12</Value>
<Code>C78746</Code>
</Quantity>
<Sig>
<SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText>
</Sig>
<Response>
<ResponseStatus>
<Approved>
<AuthorizationNumber>PA1000001</AuthorizationNumber>
<AuthorizationPeriod>
<EffectiveDate>
</EffectiveDate>
<ExpirationDate>
</ExpirationDate>
</AuthorizationPeriod>
<Appeal>
<IsEAppealSupported>Y</IsEAppealSupported>
</Appeal>
</Approved>
</ResponseStatus>
</Response>
</PAResponse>
</Body>
</Message>
Notes:
Element Value Note
MessageID 8890 Payer system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234569 Message ID from the PARequest.
PAResponse PAResponse The transaction type: PA Response.
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Element Value Note
ase
Gender F Female
CLANCY, WI, 54999
0.4 ML PREFILLED
SYRINGE

SUBCUTANEOUSLY
ONCE DAILY
Response
ResponseType
Approved The included composite contains approval information.
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Element Value Note
AuthorizationNumber PA1000001
AuthorizationPeriod
EffectiveDate 2013-10-01T00:01:01 Approval start date.
ExpirationDate 2014-09-30T23:59:59 Approval expiration date.
Appeal Appeal-related information is always required.
IsEAppealSupported Y Indicates that this determination may be appealed. (Yes)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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1.34 EXAMPLE 34. PRIOR AUTHORIZATION DENIAL AND APPEAL
This example illustrates a scenario where the prescriber receives a denial in a PAResponse and chooses to respond to the Payer with a
PAAppealRequest. The Payer acknowledges the request with a Status response, and then returns a PAAppealResponse approving the appeal
request. The prescriber system replies with a Status response.
The requested medication is Symbicort (Symbicort 80/4.5 Metered Dose Inhaler, 60 ACTUAT; RxNorm SBD 1246315; NDC 00186037228).
The prior authorization questions to be completed by the prescriber are:
1. What is the indication for the prescribed medication? (Free text)
2. Indicate whether the patient exhibit an inadequate response to treatment with at least a 30 day trial of any of the following
medications (select all that apply).
• Flovent
• Asmanex
• Qvar
• Advair
• Dulera
(Select question type, SelectMultiple=N)
In the appeal request, the provider includes the following additional information:
“The patient has a documented allergy to Advair (fluticasone, salmeterol), and has unsuccessfully tried Flovent, Asmanex, Qvar and
Dulera”
Transaction
Status (from Payer)
Status (from Payer)
PAAppealRequest (From Prescriber)
Status (from Payer)
PAAppealResponse (From Payer)
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PAInitiationRequest
Status
After elapsed time
Status
After elapsed time
PARequest
Status
Prescriber
Payer
After elapsed time
PAResponse
Status
After elapsed time
PAAppealRequest
Status
After elapsed time
PAAppealResponse
Status
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<PAReferenceID> is 99QQQ
PAInitiationRequest from PAInitiationResponse PARequest from PAResponse from Payer PAAppealRequest from PAAppealResponse from
Prescriber from Payer Prescriber Prescriber Payer
<MessageID> 1234567 X53 1234569 8890 1234571 8892
<RelatesToMessageID> 1234567 X53 1234569 8890 1234571
<RxReferenceNumber>
<PAReferenceID> 99QQQ 99QQQ 99QQQ 99QQQ 99QQQ 99QQQ
<PACaseID> A102 A102 A102 A102 A102
<AppealCaseID>
Status from Payer Status from Prescriber Status from Payer Status from Prescriber Status from Payer Status from Prescriber
<MessageID> 8888 95 9XX 1234570 9QQ 1234577

<RelatesToMessageID> 1234567 X53 1234569 8890 1234571 8892
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAReferenceID>99QQQ</PAReferenceID>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
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</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>SYMBICORT 80/4.5 METERED DOSE INHALER, 120 ACTUAT</DrugDescription>
<DrugCoded>
<Strength>
<StrengthValue>80/4.5</StrengthValue>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
<Code>C48155</Code>
</Quantity>
<Sig>
<SigText>TWO INHALATIONS TWICE DAILY</SigText>
</Sig>
</Body>
</Message>
Notes:
Element Value Note
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355
Element Value Note
ase
PAReferenceID 99QQQ Assigned by the prescribing system on the initial transaction and is used as
Gender F Female
CLANCY, WI, 54999
DrugDescription SYMBICORT 80/4.5 Drug prescribed is Symbicort 80/4.5 Metered Dose Inhaler, 120 ACTUAT
METERED DOSE
INHALER, 120 ACTUAT
Strength, 80/4.5 80/4.5 mcg/puff is the strength.
StrengthForm C91148 C91148 is the code for “metered dose inhaler”.
StrengthUnitOfMeasure C48152 C48152 is the code for “micrograms”.
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Element Value Note
Quantity 20.4:38 The quantity is 2 inhalers of 10.2 grams each. 38 is the code value for
Original Qty.
QuantityUnitOfMeasure C48152 C48152 is the code for “Grams”.

SigText TWO INHALATIONS TWO INHALATIONS TWICE DAILY …. is the Sig.
TWICE DAILY
Status (from Payer)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
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<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
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<Code>C48155</Code>
</Quantity>
<Sig>
<SigText>TWO INHALATIONS TWICE DAILY</SigText>
</Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
<QuestionSetTitle>Symbicort PA Form</QuestionSetTitle>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionText>What is the indication for the prescribed medication?</QuestionText>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
<Question>
<QuestionText>Indicate whether the patient exhibits an inadequate response to treatment with at least a 30 day trial of any of the following medications (select all that apply).</QuestionText>
<QuestionType>
<Select>
<SelectMultiple>Y</SelectMultiple>
<Choice>
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<ChoiceText>Flovent</ChoiceText>
</Choice>
<Choice>
<ChoiceText>Asmanex</ChoiceText>
</Choice>
<Choice>
<ChoiceText>Qvar</ChoiceText>
</Choice>
<Choice>
<ChoiceText>Advair</ChoiceText>
</Choice>
<Choice>
<ChoiceText>Dulera</ChoiceText>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Date>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
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<Choice>
</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Numeric>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
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Element Value Note
ase
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
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Element Value Note
Quantity 20.4:38 The quantity is 2 inhalers pf 10.2 grams each. 38 is the code value for
Original Qty.

TWICE DAILY
Response
ResponseStatus Open
QuestionSet
Header
QuestionSetID QS102 Payer -assigned ID for this question set.
QuestionSetTitle Symbicort PA Form The title of the question set, “Symbicort PA Form” can be presented to the
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
QuestionText What is the indication Question text to be displayed to the end-user.
for the prescribed
medication?
Question 2
Question
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Element Value Note
QuestionText Indicate whether the Question text to be displayed to the end-user.
patient exhibits an
inadequate response to
treatment with at least
a 30 day trial of any of
the following
medications (select all
that apply).
SelectMultiple Y Multiple answers may be returned for this question (Yes)
Choice First choice
ChoiceText Flovent Text to be presented to the end-user
Choice First choice
ChoiceText Asmanex Text to be presented to the end-user
Choice First choice
ChoiceText Qvar Text to be presented to the end-user
Choice First choice
ChoiceText Advair Text to be presented to the end-user
ChoiceText Dulera Text to be presented to the end-user

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
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</SenderSoftware>
</Header>
<Body>
<PARequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
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</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
<Code>C48155</Code>
</Quantity>
<Sig>
<SigText>TWO INHALATIONS TWICE DAILY</SigText> </Sig>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
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<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionType>
<FreeText>
<Answer>
<PrescriberProvidedAnswer>Asthma</PrescriberProvidedAnswer>
</Answer>
</FreeText>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
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<Choice>
</Choice>
<Choice>
</Choice>
<Answer>
</Answer>
<Answer>
</Answer>
<Answer>
</Answer>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</PARequest>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
RelatesToMessageID X53 Message ID from the PAInitiationResponse.
ase
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.
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Element Value Note
TWICE DAILY
Request
QuestionSet
Header
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
for the prescribed
medication?
Answer
PrescriberProvidedAnswer Asthma
Question 2
Question
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Element Value Note
patient exhibits an
the following
that apply).
Choice First choice
Choice First choice
Choice First choice
Choice First choice
Answer
ChoiceID Q2C1 ChoiceID associated with a selected choice.
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Element Value Note
Status (from Payer)

<Header>
<MessageID>9XX</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>

<Header>
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<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
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</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
<Code>C48155</Code>
</Quantity>
<Sig>
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<Response>
<ResponseStatus>
<Denied>
<Appeal>
</Appeal>
<PANote>Advair must be tried prior to approval for Symbicort</PANote>
</Denied>
</ResponseStatus>
</Response>
</PAResponse>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID 1234569 Message ID from the PARequest.
PAResponse PAResponse The transaction type: PA Response.
ase
Gender F Female
CLANCY, WI, 54999
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Element Value Note
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.

TWICE DAILY
Response
ResponseType
Denied The included composite contains denial information.
PANote Advair must be tried Note from the Payer clarifying the response.
prior to approval for
Symbicort.

<Header>
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<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
PAAppealRequest (from Prescriber)

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAAppealRequest>
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<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
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</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
<Code>C48155</Code>
</Quantity>
<Sig>
<Request>
<PANote>The patient has a documented allergy to Advair (fluticasone, salmeterol), and has unsuccessfully tried Flovent, Asmanex, Qvar and Dulera.</PANote>
</Request>
</PAAppealRequest>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
RelatesToMessageID 8890 Message ID from the PAResponse.
PAAppealRequest PAAppealRequest The transaction type: PA Appeal Request.
SentTime 2013-10-01T12:17:22 Date and time transaction was sent 10/01/2013 12:17:22 PM
ase
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.
QuantityUnitOfMeasure C62275 C62275 is the code for “inhaler”.
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Element Value Note
TWICE DAILY
Request
PANote The patient has a Note from the prescriber clarifying the need for the PA.
documented allergy to
Advair (fluticasone,
salmeterol), and has
unsuccessfully tried
Flovent, Asmanex, Qvar
and Dulera.
Status (from Payer)

<Header>
<MessageID>9QQ</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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PAAppealResponse (from Payer)
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PAAppealResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
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</Strength>
</DrugCoded>
<Quantity>
<Value>2</Value>
<Code>C62275</Code>
</Quantity>
<Sig>
<Response>
<ResponseStatus>
<Approved>
<Appeal>
</Appeal>
<AppealCaseID>122345</AppealCaseID>
</Approved>
</ResponseStatus>
</Response>
</PAAppealResponse>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID 1234571 Message ID from the PAAppealRequest.
PAAppealResponse PAAppealResponse The transaction type: PA Appeal Response.
SentTime 2013-10-01T13:20:22 Date and time transaction was sent 10/1/2013 13:20:22 PM
ase
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Element Value Note
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.

TWICE DAILY
Response
ResponseType
Approved The included composite contains denial information.
PACaseID A102 Payer-assigned identifier for the original prior authorization request.
PAAppealCaseID 122345 Payer-assigned identifier for the appeal request.
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Element Value Note
Note Prior authorization is Note from the Payer clarifying the response.
granted for the
medication as
prescribed, for one
year’s supply.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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1.35 EXAMPLE 35. PRIOR AUTHORIZATION WITH CODED REFERENCE
This example illustrates use by a Payer of a coded reference to request patient clinical information and use of the coded reference answer by the
prescriber system in the PARequest.
The example is presented as a variation on the example above, Prior Authorization Denial and Appeal, and only the changed transactions are
shown below:
• The PAInitiationReponse sent by the Payer is modified to add a CodedReference to question #1.
• The PARequest sent by the prescriber system to the Payer is modified to include a CodedReferenceAnswer to question #1.
In this example, the free text question “What is the indication for the prescribed medication?” is accompanied by a coded reference to the CCDA
Indication template (OID: 2.16.840.1.113883.10.20.22.4.19), and the prescriber system supplies the answer using a completed Indication
template.
Transaction
Status (from Payer)
Shown: PAInitiationResponse (from Payer)
Shown: PARequest (from Prescriber)
Status (from Payer)
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PAInitiationRequest from PAInitiationResponse PARequest from PAResponse from Payer

Prescriber from Payer Prescriber
<MessageID> 1234567 X53 1234569 8890
<RxReferenceNumber>
<PAReferenceID> 99QQQ 99QQQ 99QQQ 99QQQ
<AppealCaseID>
<MessageID> 8888 95 9XX 1234570

<RelatesToMessageID> 1234567 X53 1234569 8890
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
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390
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
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<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>20.4</Value>
</Quantity>
<Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
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392
<Header>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<CodedReference>
<CodeSystemVersion>1.1</CodeSystemVersion>
<Qualifier>HL7OID</Qualifier>
<Code>2.16.840.1.113883.10.20.22.4.19</Code>
<Description>INDICATION</Description>
</CodedReference>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
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<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Date>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
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394
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Numeric>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
Element Value Note
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Element Value Note
ase
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.

TWICE DAILY
Response
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Element Value Note
ResponseStatus Open
QuestionSet
Header
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
for the prescribed
medication?
CodedReference
CodeSystemVersion 1.1 Consolidated CDA release 1.1 (use appropriate actual version)
Qualifier HL7OID HL7 OID
Code 2.16.840.1.113883.10.2 OID for the CCDA Indication template
0.22.4.19
Description Indication Indication for use of this medication
Question 2
Question
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Element Value Note
patient exhibit an
the following
that apply).
Choice First choice
Choice First choice
Choice First choice
Choice First choice
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398
<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PARequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
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</Strength>
</DrugCoded>
<Quantity>
<Value>2</Value>
<Code>C62275</Code>
</Quantity>
<Sig>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<CodedReference>
<CodeSystemVersion>1.1</CodeSystemVersion>
<Qualifier>HL7OID</Qualifier>
<Code>2.16.840.1.113883.10.20.22.4.19</Code>
<Description>INDICATION</Description>
</CodedReference>
<QuestionType>
<FreeText>
<Answer>
<CodedReferenceAnswer>
<Attachment>
<AttachmentSource>Patient Medical Record</AttachmentSource>
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401
<AttachmentData></AttachmentData>
<CDA>
<TemplateID>2.16.840.1.113883.10.20.22.4.19</TemplateID>
</CDA>
<MIMEType>application/hl7-sda+xml</MIMEType>
</Attachment>
</CodedReferenceAnswer>
</Answer>
</FreeText>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
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402
<Answer>
</Answer>
<Answer>
</Answer>
<Answer>
</Answer>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</PARequest>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID X53 Message ID from the PAInitiationResponse.
ase
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Element Value Note
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.

TWICE DAILY
Request
QuestionSet
Header
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404
Element Value Note
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
for the prescribed
medication?
CodedReference
CodeSystemVersion 1.1 Consolidated CDA release 1.1 (use appropriate actual version)
Qualifier HL7OID HL7 OID
Code 2.16.840.1.113883.10.2 OID for the CCDA Indication template
0.22.4.19
Description Indication Indication for use of this medication
Q2 Next question to display regardless of the answer to this question.
DefaultNextQuestionID
Answer (Example only)
CodedReferenceAnswer
Attachment
AttachmentSource Patient medical record Indicates that the information was retrieved from the patient’s medical
record
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Element Value Note
AttachmentData Base64-encoded string, <observation classCode="OBS" moodCode="EVN">
completed Indication 
template (see Note <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
column for non- <id extension="123456789" root="2.16.840.1.113883.19"/>
encoded content) <code code="409586006"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT® "
displayName="Complaint"/>
<statusCode code="completed"/>
<value xsi:type="CD"
code="195967001"
codeSystem="2.16.840.1.113883.6.96"
facodeSystemName="SNOMED CT® "
displayName="Asthma"/>
</observation>
ClinicalInformation
CDA
TemplateID 2.16.840.1.113883.10.2 Indications CCDA template ID
0.22.4.19
MIMEType application/hl7-sda+xml MIME type for CDA
Question 2
Question
patient exhibit an
the following
that apply).
Choice First choice
Choice First choice
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Element Value Note
Choice First choice
Choice First choice
Answer
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407
1.36 EXAMPLE 36. PA PROCESS CANCELATION
In this example, the prescriber cancels a previously initiated prior authorization using the PACancelRequest, and the Payer responds using the
PACancelResponse.
The example is presented as a variation on the example above, Prior Authorization Denial and Appeal, and only the changed transactions are
shown below:
• The PAInitiationReponse is included to provide content that will be included in the PACancelRequest and PACancelResponse
transactions.
• The PACancelRequest sent by the prescriber system to the Payer is shown.
• The PACancelResponse returned by the Payer is shown.
• Note: The Status responses sent in response to each of the above transmissions are not shown below.
Transaction
Status (from Payer)
Shown: PAInitiationResponse (from Payer)
Shown: PACancelRequest (from Prescriber)
Status (from Payer)
Shown: PACancelResponse (from Payer)
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PAInitiationRequest from PAInitiationResponse PACancelRequest from PACancelResponse from

Prescriber from Payer Prescriber Payer
<MessageID> 1234567 X53 1234677 XX32
<RxReferenceNumber>
<PAReferenceID> 99QQQ 99QQQ 99QQQ 99QQQ
<AppealCaseID>
<MessageID> 8888 95 9XX 1234570

<RelatesToMessageID> 1234567 X53 1234677 XX32
<RxReferenceNumber>

<Header>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
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<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
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410
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>2</Value>
<Code>C62275</Code>
</Quantity>
<Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
</DeadlineForReply>
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411
<QuestionSet>
<Header>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
<Choice>
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412
</Choice>
<Choice>
</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Date>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
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413
</Select>
</QuestionType>
</Question>
<Question>
<QuestionType>
<Numeric>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionType>
<FreeText>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
Element Value Note
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414
Element Value Note
ase
Gender F Female
CLANCY, WI, 54999
METERED DOSE
INHALER, 120 ACTUAT
Original Qty.

TWICE DAILY
Response
ResponseStatus Open
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415
Element Value Note
QuestionSet
Header
end-user.
result in delayed
processing or an
for insufficient
information.
umber process.
Question 1
Question
for the prescribed
medication?
Question 2
Question
patient exhibit an
the following
that apply).
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416
Element Value Note
Choice First choice
Choice First choice
Choice First choice
ChoiceID Q2C3 Payer assigned ID for this choice
Choice First choice
PACancelRequest (from Prescriber)

<Header>
<Security>
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417
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PACancelRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
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</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C91148</Code>
</StrengthForm>
<Code>C48152</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>2</Value>
<Code>C62275</Code>
</Quantity>
<Sig>
<Request>
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419
<CancelReasonCode>BW</CancelReasonCode>
<IsPatientNotified>Y</IsPatientNotified>
</Request>
</PACancelRequest>
</Body>
</Message>
Notes:
Element Value Note
RelatesToMessageID X53 MessageID of PAInitiationResponse.
PACancelRequest PACancelRequest The transaction type: PA Cancelation Request.
ase
Request
CancelReasonCode BW Changed to a different medication.
IsPatientNotified Y Indicates that the patient is aware of the cancelation. (Yes)
…
PACancelResponse (from Payer)
<Header>
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420
<MessageID>XX32</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<PACancelResponse>
<Response>
<ResponseStatus>
<Approved>
<PANote>PA Case A102 was successfully canceled. For further questions, call 555-555-1212.</PANote>
</Approved>
</ResponseStatus>
</Response>
</PACancelResponse>
</Body>
</Message>
Notes:
Element Value Note
MessageID XX32 Payer system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234677 Message ID from the PACancelRequest.
PACancelResponse PACancelResponse The transaction type: PA Cancelation Response.
ase
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Element Value Note
Response
PACaseID A102 Payer-assigned identifier for the original prior authorization request.
ResponseStatus
Approved Indicates that the Payer was able to cancel the PA process before it had
completed.
Note PA Case A102 was Note from the Payer providing additional information.
successfully canceled.
For further questions,
call 555-555-1212.
1.37 EXAMPLE 37. RXTRANSFER (ALL)

In this example, a pharmacy (Pharmacy 1) sends a request to transfer ALL prescribed prescriptions and the receiving pharmacy (Pharmacy 2)
responds. Pharmacy 2 has one prescription to transfer, the NewRx they recently received. In the transfer the <HistoryPrescriberOrderNumber>
contains the <PrescriberOrderNumber> from the NewRx which provides the trace back that Pharmacy 1 can use in further exchanges with the
prescribing system. This should be taken as a completely new example.
Transaction
NewRx sent to Pharmacy 2 (from prescriber)
Status to prescriber (from Pharmacy 2)
RxTransferRequest (from Pharmacy 1)

Status (from Pharmacy 2)
RxTransferResponse (from Pharmacy 2)
RxTransferConfirm (from Pharmacy 1)
Pharmacy 1 sends Pharmacy 2 sends Pharmacy 1 sends

NewRx from Prescriber Pharmacy 2 RxTransferResponse to Pharmacy 2
sent to Pharmacy 2 RxTransferRequest Pharmacy 1 RxTransferConfirm
<MessageID> 1234567 888 3433 9999
Status from Pharmacy 2 Status from Pharmacy 2 Status from Pharmacy 1 Status from Pharmacy 2
<MessageID> ABC11 ABC22 9988 ABC99
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422
<RelatesToMessageID> 1234567 888 3433 9999

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
<SecondaryIdentification>PASSWORDAAA</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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423
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<BusinessName>CHENG PHARMACY</BusinessName>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
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424
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
<RxFillIndicator>All Fill Statuses</RxFillIndicator>
</NewRx>
</Body>
</Message>
Notes:
Element Value Note
To 9801930:P NCPDP Provider ID Number of pharmacy 2; P means it is a pharmacy. This
is the destination.
SecondaryIdentification PASSWORDAAA The password of the Clinic to Pharmacy 2.
ase
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425
Element Value Note
Gender F Female
CLANCY, WI, 54999
NCPDPID 9801930 NCPDP Provider ID Number of Pharmacy 2.
StoreName CHENG PHARMACY Name of Pharmacy
tablets.
TIMES A DAY UNTIL
GONE
patient/medication.
<Header>
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426
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
From 9801930:P Pharmacy 2 ID. Now the sender.
MessageID ABC111 Pharmacy 2 trace number for this transmission.
RelatesToMessageID 1234567 Prescriber trace number is used to link the (MessageID) from

<Header>
<Security>
<UsernameToken>
</UsernameToken>
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427
<Sender>
<SecondaryIdentification>PASSWORDC</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<AddressLine1>400 S AMES ST</AddressLine1>
<City>SMITH</City>
<StateProvince>NJ</StateProvince>
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428
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
<TransferType>TRANSFER FROM PHARMACY</TransferType>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
<AddressLine1>5400 S 121 STREET</AddressLine1>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
<TransferType>TRANSFER TO PHARMACY</TransferType>
</Pharmacy>
<TransferRequest>ALL</TransferRequest>
</RxTransferRequest>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
From 7701630:P This is the Pharmacy 1 ID of the sender; P means it is a pharmacy.
MessageID 888 Pharmacy 1 system trace number for the transmission. Echoed back in
the response transaction in RelatesToMessageID.
SecondaryIdentification PASSWORDC The password of the Pharmacy 1 to Pharmacy 2.
RxTransferRequest RxTransferRequest The transaction type: RxTransferRequest
ase
PrescriberOrderNumber Not sent. Not applicable
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429
Element Value Note

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
NPI 8888855555 National Provider ID of Pharmacy 2.
StoreName CHENG PHARMACY Name of Pharmacy 2
Address 400 S AMES ST….. Address of Pharmacy 2
CommunicationNumber 9081129911 Phone Number of Pharmacy 2 (908) 112-9911.
Transfer To Pharmacy
NPI 7878787878 National Provider ID of Pharmacy 1
StoreName MAIN STR… Name of Pharmacy 1
Address 5400 S 121 ST… Address of Pharmacy 1
TransferRequest ALL Pharmacy 1 is requesting all appropriate prescriptions be transferred for
this patient.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
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430
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
To 7701630:P Pharmacy 1 ID; P means pharmacy. Now the destination.
RelatesToMessageID 888 Pharmacy 1 trace number is used to link the (MessageID) from

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
V13
431
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferResponse>
<Response>
<Approved>
</Approved>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
V13
432
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<MedicationTransferred>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
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433
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Quantity>
<Value>60</Value>
<CodeListQualifier>QT</CodeListQualifier>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
<HistoryPrescriberOrderNumber>110088</HistoryPrescriberOrderNumber>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<RxFillIndicator>All Fill Statuses</RxFillIndicator>
<RxReferenceNumber>22722</RxReferenceNumber>
V13
434
<PrescriptionPreviouslyFilled>N</PrescriptionPreviouslyFilled>
</MedicationTransferred>
</RxTransferResponse>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
From 9801930:P This is the Pharmacy 2 ID of the sender; P means it is a Pharmacy.
RelatesToMessageID 888 Pharmacy 1 trace number is used to link the (MessageID) from request to
the response.
SecondaryIdentification PASSWORD222 The password of Pharmacy 2 to Pharmacy 1.
RxTransferResponse RxTransferResponse The transaction type: RxTransferResponse.
ase
Approved Approved RxTransferResponse is Approved.

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
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435
Element Value Note
MedicationTransferred
tablets.
Quantity 60:40 The quantity is 60. 40 is the code value for Remaining Qty.
Quantity 60:QT The quantity is 60. QT is the code value for Quantity Transferred.
TIMES A DAY UNTIL
GONE
RefillsRemaining 1 One refill remains.
HistoryPrescriberOrderNum 110088 Can be used by Pharmacy 1 in future transactions with prescriber system.
ber

V13
436
Element Value Note
RxFillIndicator ALL FILL STATUSES The prescriber has requested this level of Fill Status Notification.
RxReferenceNumber 22722 Pharmacy 2 has assigned a prescription number on their system.
PrescriptionPreviouslyFilled N No, the prescription was not previously filled.
TransferRequest ALL Echoed from RxTransferRequest.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
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437
Element Value Note
MessageID 9988 Pharmacy 1 trace number for this transmission.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferConfirm>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
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438
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
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439
</PrimaryTelephone>
</Pharmacy>
<Pharmacist>
<Identification>
<StateLicenseNumber>A523339X</StateLicenseNumber>
</Identification>
<Name>
<LastName>EVERETT</LastName>
<FirstName>TERESA</FirstName>
</Name>
<PrimaryTelephone>
<Extension>111</Extension>
</PrimaryTelephone>
</Pharmacist>
<RxFillConfirmIndicator>Y</RxFillConfirmIndicator>
</RxTransferConfirm>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
the response.
RxTransferConfirm RxTransferConfirm The transaction type: RxTransferConfirm.
ase

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440
Element Value Note
Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
Pharmacist
StateLicenseNumber A523339X For this example, it is assuming the state license number is to be sent per
regulations.
LastName Everett Pharmacist’s last name.
FirstName Teresa Pharmacist’s first name.
CommunicationNumber 9081129911:111 Pharmacist’s phone number and extension.
RxFillConfirmIndicator Y Pharmacy 1 supports RxFill transactions.

<Header>
<Security>
<UsernameToken>
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441
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
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442
1.38 EXAMPLE 38. RXTRANSFER (ALL – MULTIPLE PRESCRIPTIONS)
In this example, a pharmacy (Pharmacy 1) sends a request to transfer ALL prescribed prescriptions and the receiving pharmacy (Pharmacy 2)
responds. Pharmacy 2 has two prescriptions to transfer. The two prescriptions include the NewRx they recently received (see Example 36) and a
second prescription they have dispensed twice. In the transfer the <HistoryPrescriberOrderNumber> contains the <PrescriberOrderNumber>
from the NewRx which provides the trace back that Pharmacy 1 can use in further exchanges with the prescribing system. This should be taken
as a completely new example.
Transaction
NewRx sent to Pharmacy 2 (from prescriber) – see Example 36
Status to prescriber (from Pharmacy 2) – see Example 36


Pharmacy 2 RxTransferResponse to Pharmacy 2
RxTransferRequest Pharmacy 1 RxTransferConfirm
<MessageID> 888 3433 9999
Status from Pharmacy 2 Status from Pharmacy 1 Status from Pharmacy 2
<MessageID> ABC22 9988 ABC99

NewRx (from Prescriber) – see Example 36
Status (from Pharmacy 2) – see Example 36

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443
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
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444
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
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445
Element Value Note
ase

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
TransferRequest ALL Pharmacy 1 is requesting all appropriate prescriptions be transferred for
this patient.

<Header>
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446
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note

<Header>
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447
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Response>
<Approved>
</Approved>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
V13
448
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
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449
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
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450
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<RxFillIndicator>Dispensed And Partially Dispensed</RxFillIndicator>
<PrescriptionPreviouslyFilled>N</PrescriptionPreviouslyFilled>
<DrugDescription>SPRINTEC 28 DAY TABLET</DrugDescription>
<DrugCoded>
<ProductCode>
<Code>00555901658</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C78747</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<LastFillDate>
<Date>2010-08-01</Date>
</LastFillDate>
<Sig>
</Sig>
<HistorySource>
<Source>
<Reference>
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451
<NPI>8888855555</NPI>
</Reference>
<SourceQualifier>P2</SourceQualifier>
</Source>
<SourceReference>28896</SourceReference>
<FillNumber>00</FillNumber>
</HistorySource>
<DrugCoded>
<ProductCode>
<Code>00555901658</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C78747</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<LastFillDate>
<Date>2010-09-01</Date>
</LastFillDate>
<Sig>
</Sig>
<HistorySource>
<Source>
<Reference>
<NPI>8888855555</NPI>
</Reference>
</Source>
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452
</HistorySource>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C78747</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<Quantity>
<Value>28</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-08-01</Date>
</WrittenDate>
<Sig>
</Sig>
<Prescriber>
<NonVeterinarian>
<Identification>
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453
<NPI>3334444</NPI>
</Identification>
<Name>
</Name>
<Address>
<City>CLYDE</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<PrescriptionPreviouslyFilled>Y</PrescriptionPreviouslyFilled>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
the response.
ase
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Element Value Note

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
tablets.
Quantity 60:40 The quantity is 60. 40 is the code value for Remaining Qty.
Quantity 60:QT The quantity is 60. QT is the code value for Quantity Transferred.
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Element Value Note
TIMES A DAY UNTIL
GONE
RefillsRemaining 1 One refill remains.
ber
RxFillIndicator DISPENSED AND The prescriber has requested this level of Fill Status Notification.
PARTIALLY DISPENSED

RxFillIndicator DISPENSED AND The prescriber has requested this level of Fill Status Notification.
PARTIALLY DISPENSED
PrescriptionPreviouslyFilled N No, the prescription was not previously filled.
MedicationDispensed Original Fill

dosing form.
Quantity 21:87 The quantity is 21. 87 is code value for Quantity Received.
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Element Value Note
Sig TAKE 1 TABLET BY TAKE ONE TABLET…. is the Sig.
MOUTH EVERY
MORNING
HistorySource
NCPDPID 9801930 NCPDP ID of pharmacy of fill number 0, which is Pharmacy 2.
NPI 8888855555 NPI of pharmacy of fill number 0, which is Pharmacy 2.
SourceQualifier P2 The Source is the Pharmacy.
SourceReference 28896 Pharmacy 2 RxNumber.
FillNumber 00 Fill number 00 (original fill).
MedicationDispensed Subsequent fill

dosing form.
Sig TAKE AS DIRECTED ON TAKE AS DIRECTED…. is the Sig.
PACKAGE
HistorySource
FillNumber 01 Fill number 01 (subsequent fill).
dosing form.
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457
Quantity 21:38 The quantity is 21. 38 is code value for Original Quantity.
Quantity 21:40 The quantity is 21. 40 is code value for Remaining Quantity.
Quantity 21:QT The quantity is 21. QT is code value for Quantity Transferred.
NumberOfRefills 2 Two refills allowed.
Sig TAKE AS DIRECTED ON TAKE AS DIRECTED …. is the Sig.
PACKAGE
RefillsRemaining 1 One refill remaining.
ber
Prescriber
Address 151 EAST STREET, The prescriber’s address.
CLYDE, ME 11122, US
RxFillIndicator DISPENSEDANDPARTIAL The prescriber has requested this level of Fill Status Notification.
LYDISPENSED
PrescriptionPreviouslyFilled Y Yes, the prescription was previously filled.

<Header>
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458
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
MessageID 9988 Pharmacy 1 trace number for this transmission.

<Header>
<Security>
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459
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferConfirm>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
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460
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacist>
<Identification>
<StateLicenseNumber>A523339X</StateLicenseNumber>
</Identification>
<Name>
<LastName>EVERETT</LastName>
<FirstName>TERESA</FirstName>
</Name>
<PrimaryTelephone>
<Extension>111</Extension>
</PrimaryTelephone>
</Pharmacist>
<RxFillConfirmIndicator>Y</RxFillConfirmIndicator>
</RxTransferConfirm>
</Body>
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</Message>
Notes:
Element Value Note
is the destination.
the response.
RxTransferConfirm RxTransferConfirm The transaction type: RxTransferConfirm.
ase

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
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Element Value Note
Pharmacist
StateLicenseNumber A523339X For this example, it is assuming the state license number is to be sent per
regulations.
LastName Everett Pharmacist’s last name.
FirstName Teresa Pharmacist’s first name.
CommunicationNumber 9081129911:111 Pharmacist’s phone number and extension.
RxFillConfirmIndicator Y Pharmacy 1 supports RxFill transactions.

<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
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463
Element Value Note
1.39 EXAMPLE 39. RXTRANSFER (SPECIFIC)

This example uses the rules in section “Which Prescription(s) to Transfer?” to show an RxTransferRequest with the use of <TransferType> of
“SPECIFIC”. This example does not show the RxTransferResponse or RxTransferConfirm.
In this example, a pharmacy (Pharmacy 1) sends a request to transfer a SPECIFIC prescription. The patient was not able to provide the
container/label to Pharmacy 1 but the pharmacist is able to ascertain the specific drug. The receiving pharmacy (Pharmacy 2) responds.
Not shown - Pharmacy 2 transfers one prescription. (In the transfer the <HistoryPrescriberOrderNumber> contains the
<PrescriberOrderNumber> from the prescription which provides the trace back that Pharmacy 1 can use in further exchanges with the
prescribing system.) This should be taken as a completely new example.
Transaction

Pharmacy 2 RxTransferResponse to Pharmacy 2
RxTransferRequest Pharmacy 1 RxTransferConfirm
<MessageID> 888 3433 9999
Status from Pharmacy 2 Status from Pharmacy 1 Status from Pharmacy 2
<MessageID> ABC22 9988 ABC99
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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxTransferRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
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465
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<MedicationTransferRequested>
<DrugCoded>
<Strength>
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<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
</MedicationTransferRequested>
<TransferRequest>SPECIFIC</TransferRequest>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
ase

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
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467
Element Value Note
MedicationTransferRequest
ed
DrugDescription THEO DUR 300MG Dispensed drug is Theo-Dur.
Strength 300 300 is the drug strength
TransferRequest SPECIFIC Pharmacy 1 is requesting a specific prescription be transferred for this
patient and the <MedicationTransferRequested> must be sent.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
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</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
1.40 EXAMPLE 40. RXTRANSFERRESPONSE WITH TWO TRANSFERS

This example is showcasing the use of the <HistorySource> to relay that for a given prescription, a fill was transferred to Pharmacy 1 and another
fill was later transferred to Pharmacy 3. For simplicity only one prescription is shown. This is an example showing a similar situation to #6 in
section “Example Scenarios”. Pharmacy 3 is provided the information of the transfer to Pharmacy 1 so that all fills are accounted. In this example
assume the italicized exchanges have taken place. This should be taken as a completely new example.
Transaction

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<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Response>
<Approved>
</Approved>
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
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<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>8888855555</NPI>
</Identification>
<Address>
<City>SMITH</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Pharmacy>
<Identification>
<NPI>7788855555</NPI>
</Identification>
<BusinessName>MARK PHARMACY</BusinessName>
<Address>
<AddressLine1>1400 S JAMES STREET</AddressLine1>
<City>MARK</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<DrugCoded>
<ProductCode>
<Code>00555901658</Code>
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</ProductCode>
<Strength>
<StrengthForm>
<Code>C78747</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<LastFillDate>
<Date>2010-08-01</Date>
</LastFillDate>
<Sig>
</Sig>
<HistorySource>
<Source>
<Reference>
<NPI>8888855555</NPI>
</Reference>
</Source>
</HistorySource>
<DrugCoded>
<ProductCode>
<Code>00555901658</Code>
</ProductCode>
<Strength>
<StrengthForm>
<Code>C78747</Code>
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472
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<LastFillDate>
<Date>2010-09-01</Date>
</LastFillDate>
<Sig>
</Sig>
<HistorySource>
<Source>
<Reference>
<NPI>7878787878</NPI>
</Reference>
</Source>
</HistorySource>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C78747</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>28</Value>
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473
<Code>C62421</Code>
</Quantity>
<Quantity>
<Value>28</Value>
<Code>C62421</Code>
</Quantity>
<Quantity>
<Value>28</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-08-01</Date>
</WrittenDate>
<Sig>
</Sig>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>3334444</NPI>
</Identification>
<Name>
</Name>
<Address>
<City>CLYDE</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
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</Prescriber>
<PrescriptionPreviouslyFilled>Y</PrescriptionPreviouslyFilled>
</Body>
</Message>
Notes:
Element Value Note
is the destination.
the response.
ase

Gender F Female
CLANCY, WI, 54999
Transferring From
Pharmacy
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475
Element Value Note
StoreName MARK PHARMACY Name of Pharmacy 3
Address 1400 S JAMES ST… Address of Pharmacy 3
MedicationDispensed Original Fill
dosing form.
PACKAGE
HistorySource
FillNumber 00 Fill number 00 (original fill).
MedicationDispensed Subsequent fill

dosing form.
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476
Element Value Note
PACKAGE
HistorySource
FillNumber 01 Fill number 01 (subsequent fill).
dosing form.
Quantity 21:38 The quantity is 21. 38 is code for Original Quantity.
Quantity 21:40 The quantity is 21. 40 is code for Remaining Quantity.
Quantity 21:QT The quantity is 21. QT is code for Quantity Transferred.
NumberOfRefills 2 Two refills allowed.
PACKAGE
RefillsRemaining 1 One refill remaining.
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477
ber
Prescriber
Address 151 EAST STREET, The prescriber’s address.
CLYDE, ME 11122, US
RxFillIndicator DISPENSEDANDPARTIAL The prescriber has requested this level of Fill Status Notification.
LYDISPENSED
PrescriptionPreviouslyFilled Y Yes, the prescription was previously filled.
<Header>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
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478
1.41 EXAMPLE 41. RXFILLINDICATORCHANGE

This example shows the use of the RxFillIndicatorChange transaction where the prescriber notifies the pharmacy of a modification to the
<RxFillIndicator> which was previously sent on a prescription. This uses the prescription from Example 2. <RelatesToMessageID> and
<PrescriberOrderNumber> are used to provide linkage to the original prescription.
Transaction
RxFillIndicatorChange (from Prescriber)
RxFillIndicatorChange
from Prescriber
Field Name Value
<MessageID> X52UU
<RxReferenceNumber>
<MessageID> ABC11
<RelatesToMessageID> X52UU
<RxReferenceNumber>
RxFillIndicatorChange (from Prescriber)

<Header>
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479
<MessageID>X52UU</MessageID>
<Security>
<UsernameToken>
</UsernameToken>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxFillIndicatorChange>
</RxFillIndicatorChange>
</Body>
</Message>

Element Value Note
MessageID X52UU Clinic system trace number for the transmission. Echoed back in the
RelatesToMessageID 1234567 Contains the <MessageID> contents from the original NewRx (see
Example 2.)
SecondaryIdentification PASSWORDQ Password of the Clinic directly to the Pharmacy, if used, depending on
RxFillIndicatorChange RxFillIndicatorChange The transaction type: RxFillIndicatorChange
ase
V13
480
Element Value Note
RxFillIndicator NOT DISPENSED The prescriber’s change to receive RxFill Status Notifications for this
patient/medication that are not dispensed only.

<Header>
<RelatesToMessageID>X52UU</RelatesToMessageID>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note
From 7701630:P Pharmacy ID. Now the sender.
MessageID ABC11 Pharmacy trace number for this transmission.
RelatesToMessageID X52UU Prescriber trace number is used to link the (MessageID) from request to the
response.
1.42 EXAMPLE 42. REMS – STANDARD PRESCRIPTION DATA – NO QUESTIONS

Prescriber checks REMS: The REMS Administrator needs the basic prescription information. The REMS Administrator approves the prescribing of
the medication for this patient.
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481
(Please note the particular medication used in this example may/not be a REMS medication. It is for example only.)
Transaction
REMSInitiationRequest (from Prescriber)
Status (from REMS Administrator
REMSInitiationResponse (From REMS
Administrator)
REMSRequest (from Prescriber)
Status (from REMS Administrator)
REMSResponse (from REMS Administrator)
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482
REMSInitiationRequest
Status
After elapsed time
REMSInitiationResponse
Status
REMS Administrator
Prescriber
After elapsed time
REMSRequest
Status
After elapsed time
REMSResponse
Status
<REMSReferenceID> is 77XX2
V13
483
REMSInitiationRequest REMSInitiationResponse REMSRequest from REMSResponse from
from Prescriber from REMS Prescriber REMS Administrator
Administrator
<MessageID> 1234555 ABCDDDD 1234567 ABCDEFGHJJJ
<RelatesToMessageID> 1234555 ABCDDDD 1234567
<RxReferenceNumber>
<REMSReferenceID> 77XX2 77XX2 77XX2 77XX2
<REMSCaseID> A101 A101 A101
<REMSAuthorizationNumber> ABCDEFGHIJ
Status from REMS Status from Prescriber Status from REMS Status from Prescriber
Administrator Administrator
<MessageID> ABCCDDD 1234111 ABCDEFGHIJK 1234570
<RelatesToMessageID> 1234555 ABCDDDD 1234567 ABCDEFGHJJJ
<RxReferenceNumber>


<Header>
<To Qualifier="REMS">REMS123</To>
<Security>
<Sender>
<SecondaryIdentification>PASSWORDR</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
V13
484
</SenderSoftware>
</Header>
<Body>
<REMSInitiationRequest>
<REMSReferenceID>77XX2</REMSReferenceID>
<Patient>
<HumanPatient>
<Identification>
<REMSPatientID>8822333XX</REMSPatientID>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
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485
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>ELIQUIS 2.5 MG</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
<Qualifier>SBD</Qualifier>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
<SigText>TAKE ONE TABLET</SigText>
</Sig>
V13
486
</REMSInitiationRequest>
</Body>
</Message>
Notes:
Element Value Note Action
To REMS123:REM ID of REMS Administrator; REM means it is a REMS Administrator. This is
the destination. It must be the REMS Administrator.
SecondaryIdentification PASSWORDR The password of the Prescriber to the REMS Administrator.
REMSInitiationRequest REMSInitiationRequest The transaction type: REMS Initiation Request.
ase
REMSReferenceID 77XX2 Assigned by the prescribing system on the initial transaction and is used Mandatory
as a tracking identifier on all request and response REMS transactions to
tieback related REMS transactions.
REMSPatientID 8822333XX REMS ID for the patient. optional
Gender F Female
CLANCY, WI, 54999
NCPDPID 7701630 NCPDP Provider ID Number of Pharmacy. (Pharmacy is optional. It
is shown in this
example.)
StoreName MAIN STREET PHARMACY Name of Pharmacy
Address 5400 S 121 ST, HALES Address of pharmacy.
CORNERS, TN, 37122, US
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487
DrugDescription ELIQUIS 2.5 MG Drug prescribed is Eliquis 2.5 Mg Tablet..
DrugDBCode and Qualifier 1364441:SBD RxNorm code
Strength 2.5 2.5 is the strength.
StrengthForm C42998 The Source for NCPDP Drug Dosage Form Terminology- C42998 is the
code for “Tablet dosing form”. So this means the prescription is for
240mg tablets.
Quantity 30:38 The quantiy is 30. 38 is the code value for Original Qty.
QuantityUnitOfMeasure C48542 The Source for NCPDP QuanityUnitOfMeasure Terminology- C48542 is the
SigText TAKE ONE TABLET… TAKE ONE TABLET…. is the Sig.
StructuredSig …

<Header>
<From Qualifier="REMS">XXXXXX</From>
<MessageID>ABCCDDD</MessageID>
<Security>
<Sender>
<SecondaryIdentification>PASSWORDRA</SecondaryIdentification>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
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488
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
Element Value Note Action:
To 77777777:C Clinic ID This is the sender. C means it is a Clinic.
From XXXXXX:R ID of REMS Administrator; R means it is a REMS Administrator. This is the
destination. It must be the REMS Administrator.
MessageID ABCCDDD REMS Administrator system trace number for the transmission.
RelatesToMessageID) 1234555 Prescriber trace number is used to link the original transaction (value in
MessageID) from request to the response.
REMSReferenceID Not sent. Not applicable.
SecondaryIdentification PASSWORDRA Password of the REMS Administrator directly to the Prescribing System, if
used, depending on trading partner agreements.
REMSInitiationResponse (from REMS Administrator)

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSInitiationResponse>
<Patient>
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489
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
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490
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
<Response>
<ResponseStatus>
<Open>
<REMSCaseID>A101</REMSCaseID>
<DeadlineForReply>
<Date>2015-11-01</Date>
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491
</DeadlineForReply>
</Open>
</ResponseStatus>
</Response>
</REMSInitiationResponse>
</Body>
</Message>
Notes:
MessageID ABCDDDD REMS Administrator system trace number for the transmission. Echoed
back in the response transaction in RelatesToMessageID.
RelatesToMessageID 1234555 Message ID from the REMSInitiationRequest.
SecondaryIdentification PASSWORDRA The password of the REMS Administrator to the Clinic System.
REMSInitiationResponse REMSInitiationResponse The transaction type: REMS Initiation Response.
ase
as a tracking identifier on all request and response prior authorization
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
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492
240mg tablets.
ResponseStatus Open
REMSCaseID A101 REMS Administrator-assigned identifier for this case. Mandatory
DeadlineForReply 2015-11-01T23:59:59

<Header>
<To Qualifier="REMS">XXXXXX</To>
<RelatesToMessageID>ABCDDDD</RelatesToMessageID>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
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493
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
To XXXXXX:R ID of REMS Administrator; R means it is a REMS Administrator. This is the
MessageID 1234111 Prescriber trace number for the transmission.
RelatesToMessageID) ABCDDDD REMS Administrator system trace number is used to link the original
transaction (value in MessageID) from request to the response.
SecondaryIdentification PASSWORDR Password of the REMS Administrator directly to the Clinic System, if used,
depending on trading partner agreements.

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
V13
494
</SenderSoftware>
</Header>
<Body>
<REMSRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
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495
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
<Request>
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496
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
</SolicitedModel>
</Request>
</REMSRequest>
</Body>
</Message>
Notes:
RelatesToMessageID ABCDDDD
SecondaryIdentification PASSWORDR Password of the Clinic directly to the REMS Administrator, if used,
REMSREQUEST REMSRequest The transaction type: REMSRequest Add new transaction
type
ase
REMSPatientID 8822333XX REMS ID for the patient.
Gender F Female
CLANCY, WI, 54999
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497
NPI 7878787878 National Provider ID of Pharmacy. (Pharmacy is optional.
It is shown in this
example.)
DrugDescription ELIQUIS 2.5MG Drug prescribed is Eliquis 2.5 Mg.
240mg tablets.
Structured Sig ….

<Header>
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498
<MessageID>ABCDEFGHIJK</MessageID>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
MessageID ABCDEFGHIJK REMS Administrator system trace number for the transmission.

<Header>
<MessageID>ABCDEFGHJJJ</MessageID>
V13
499
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
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500
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
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501
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
<Response>
<ResponseStatus>
<Approved>
<REMSAuthorizationNumber>ABCDEFGHIJ</REMSAuthorizationNumber>
</Approved>
</ResponseStatus>
</Response>
</REMSResponse>
</Body>
</Message>
Notes:
MessageID ABCDEFGHJJJ REMS Administrator system trace number for the transmission.
REMSRESPONSE REMSResponse The transaction type: REMSResponse New transaction
Gender F Female
CLANCY, WI, 54999
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502
NCPDPID 7701630 NCPDP Provider ID Number of Pharmacy. (Pharmacy is optional.
It is shown in this
example.)
StoreName MAIN STREET PHARMACY Name of pharmacy.
777, US
DrugDescription ELIQUIS 2.5MG Drug prescribed is Eliquis 2.15mg.
240mg tablets.
Structured Sig
ResponseStatus Approved
REMSCaseID R101 REMS Administrator-assigned identifier for this case. Mandatory
REMSAuthorizationNumber ABCDEFGHIJ optional
REMS Note optional

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503
<Header>
<RelatesToMessageID>ABCDEFGHJJJ</RelatesToMessageID>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
RelatesToMessageID) ABCDEFGHJJJ REMS Administrator system trace number is used to link the original
V13
504
1.43 EXAMPLE 43: REMS – STANDARD PRESCRIPTION DATA – NO QUESTIONS – CLOSED
Prescriber checks REMS: The REMS Administrator needs the basic prescription information. The REMS Administrator does not approve the
prescribing of the medication for this patient because a Diagnosis Code was not submitted.
Transaction
Status (from REMS Administrator
REMSInitiationResponse (From REMS Administrator)
V13
505
Status
After elapsed time
Status
REMS Administrator
Prescriber
After elapsed time
REMSRequest
Status
After elapsed time
REMSResponse
Status
V13
506
REMSInitiationReques REMSInitiationRespon REMSRequest from REMSResponse from
t from Prescriber se from REMS Prescriber REMS Administrator
Administrator
<RxReferenceNumber>
<REMSAuthorizationNumber> ABCDEFGHIJ
<RxReferenceNumber>

<Header>
<Security>
<Sender>
V13
507
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
V13
508
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
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509
<Sig>
</Sig>
</Body>
</Message>
Notes:
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
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510
240mg tablets.
StructuredSig …

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
V13
511
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
V13
512
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
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513
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
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514
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
<Date>2015-11-01</Date>
</DeadlineForReply>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
V13
515
240mg tablets.
ResponseStatus Open

<Header>
<Security>
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516
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:

<Header>
<Security>
<Sender>
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517
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
V13
518
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48542</Code>
</Quantity>
V13
519
<Sig>
</Sig>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
</SolicitedModel>
</Request>
</REMSRequest>
</Body>
</Message>
Notes:
SecondaryIdentification PASSWORDR Password of the Prescriber system directly to the REMS Administrator, if
REMSREQUEST REMSRequest The transaction type: REMSRequest
ase
Gender F Female
CLANCY, WI, 54999
V13
520
It is shown in this
example.)
DrugDescription ELIQUIS 2.5 MG Drug prescribed is Eliquis 2.5mg.
240mg tablets.
Structured Sig ….

<Header>
V13
521
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:

<Header>
V13
522
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
V13
523
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
V13
524
<Code>C48542</Code>
</Quantity>
<Sig>
</Sig>
<Response>
<ResponseStatus>
<Closed>
<REMSCaseID>R101</REMSCaseID>
<ClosedReasonCode>BX</ClosedReasonCode>
<REMSNote>Prescribing not authorized due to laboratory test results</REMSNote>
</Closed>
</ResponseStatus>
</Response>
</REMSResponse>
</Body>
</Message>
Notes:
REMSRESPONSE REMSResponse The transaction type: REMSResponse New transaction
Gender F Female
CLANCY, WI, 54999
V13
525
It is shown in this
example.)
777, US
DrugDescription ELIQUIS 2.5 MG Drug prescribed is Eliquis 2.5mg.
240mg tablets.
Structured Sig
ResponseStatus Closed
REMSCaseID R101 REMS Administrator-assigned identifier for this case. Mandatory
REMSNote Prescribing not
authorized due to
laboratory test results
V13
526
<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
V13
527
1.44 EXAMPLE 44: REMS – QUESTIONS – APPROVED
Prescriber checks REMS: The REMS Administrator needs the basic prescription information plus some questions answered before the prescribing for this REMS
medication can be approved. The prescriber answers the questions.
Transaction
Status (from REMSAdministrator)
REMSInitiationResponse (from REMS
Administrator)
V13
528
Status
After elapsed time
Status
REMS Administrator
Prescriber
After elapsed time
REMSRequest
Status
After elapsed time
REMSResponse
Status
<REMSReferenceID> is 77XX2
REMSInitiationReques REMSInitiationRespon REMSRequest from REMSResponse from

t from Prescriber se from REMS Prescriber REMS Administrator
Administrator
V13
529
<RxReferenceNumber>
<REMSAuthorizationNumber> BCDEFGH
<RxReferenceNumber>

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
V13
530
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
V13
531
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>JUXTAPID 10 MG ORAL CAPSULE</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Sig>
<SigText>TAKE 1 CAPSULE DAILY PER MOUTH</SigText>
</Sig>
</Body>
</Message>
V13
532
Notes:
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
DrugDescription JUXTAPID 10 MG ORAL Drug prescribed is Juxtapid 10 MG oral capsule.
CAPSULE
DrugDBCode and Qualifier 1364490:SBC RxNorm code
V13
533
StrengthForm C25158 C25158 is the code for “capsule”.
StrengthUnitOfMeasure C28253 C28253 is the code for used for “milligram”.
QuantityUnitOfMeasure C48480 C48480 is the code for “capsule”.
SigText TAKE 1 CAPSULE DAILY TAKE 1 CAPSULE DAILY PER MOUTH …. is the Sig.
PER MOUTH
StructuredSig …

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
From XXXXXX:REM ID of REMS Administrator; REM means it is a REMS Administrator. This is
V13
534

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
V13
535
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
<CountryCode>1</CountryCode>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
V13
536
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Sig>
</Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
<Date>2015-11-01</Date>
</DeadlineForReply>
<QuestionSet>
<Header>
<QuestionSetTitle>Juxtapid REMS Form</QuestionSetTitle>
<PrimaryTelephone>
</PrimaryTelephone>
V13
537
</Header>
<Question>
<QuestionText>I understand that JUXTAPID is indicated as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available, to reduce low-density lipoprotein
cholesterol (LDL-C), total cholesterol (TC), apolipoprotein B (apo B) and non-high-density lipoprotein cholesterol (non-HDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). I affirm that my patient has a
clinical or laboratory diagnosis consistent with HoFH. I understand that JUXTAPID has not been studied in pediatric patients less than 18 years. I attest that I have obtained the liver-related laboratory tests for this patient as
directed in JUXTAPIDs prescribing information.</QuestionText>
<QuestionType>
<Select>
<Choice>
<ChoiceText>YES</ChoiceText>
</Choice>
<Choice>
<ChoiceText>NO</ChoiceText>
</Choice>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
V13
538
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
CAPSULE
PER MOUTH
ResponseStatus Open
V13
539
QuestionSet
QuestionSet A question set is included in the REMS Administrator’s response.
Header
QuestionSetID QS101 REMS Administrator-assigned ID for this question set.
QuestionSetTitle Juxtapid REMS Form The title of the question set, “Juxtapid REMS Form” can be presented to
the end-user.
result in delayed
processing or an adverse
determination for
insufficient information.
QuestionSetContactPhoneN 5555551212 Contact phone number at the REMS Administrator for questions related
umber to this REMS process.
Question 1
Question
QuestionID Q1 REMS Administrator-assigned ID for this question.
V13
540
QuestionText I understand that JUXTAPID Question text to be displayed to the end-user.
is indicated as an adjunct to a
low-fat diet and other lipid-
lowering treatments,
including LDL apheresis
where available, to reduce
low-density lipoprotein
cholesterol (LDL-C), total
cholesterol (TC),
apolipoprotein B (apo B) and
non-high-density lipoprotein
cholesterol (non-HDL-C) in
patients with homozygous
familial
hypercholesterolemia
(HoFH).
I affirm that my patient has a
clinical or laboratory
diagnosis consistent with
HoFH.
I understand that JUXTAPID
has not been studied in
pediatric patients less than
18 years.
I attest that I have obtained
the liver-related laboratory
tests for this patient as
directed in JUXTAPID’s
prescribing information.
DefaultNextQuestionID END This is the last question in the question set.
Choice First choice
ChoiceID Q1C1 REMS Administrator-assigned ID for this choice
ChoiceID Q1C2 REMS Administrator -assigned ID for this choice
V13
541
<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
To XXXXXX:REM ID of REMS Administrator; REM means it is a REMS Administrator. This is

V13
542
<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
V13
543
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
V13
544
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionText>I understand that JUXTAPID is indicated as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available, to reduce low-density lipoprotein cholesterol (LDL-
C), total cholesterol (TC), apolipoprotein B (apo B) and non-high-density lipoprotein cholesterol (non-HDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). I affirm that my patient has a clinical or laboratory
diagnosis consistent with HoFH. I understand that JUXTAPID has not been studied in pediatric patients less than 18 years. I attest that I have obtained the liver-related laboratory tests for this patient as directed in JUXTAPIDs
prescribing information.</QuestionText>
<QuestionType>
<Select>
<Choice>
</Choice>
V13
545
<Choice>
</Choice>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</REMSRequest>
</Body>
</Message>
Notes:
MessageID 1234567 Prescriber trace number is used to link the original transaction (value in
RelatesToMessageID ABCDDDD REMS Administrator trace number is used to link the original transaction
(value in MessageID) from request to the response.
SecondaryIdentification PASSWORDR Password of the Clinic System directly to the REMS Administrator, if used,
ase
V13
546
Gender F Female
CLANCY, WI, 54999
CAPSULE
Structured Sig
QuestionSet
Header
QuestionSetID QS101 REMS Adminstrator-assigned ID for this question set.
V13
547
the end-user.
result in delayed
determination for
Question 1
Question
cholesterol (TC),
familial
(HoFH).
HoFH.
18 years.
V13
548
Choice First choice
Answer

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
V13
549
Notes:

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
V13
550
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
V13
551
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Response>
<ResponseStatus>
<Approved>
<REMSAuthorizationNumber>BCDEFGH</REMSAuthorizationNumber>
</Approved>
</ResponseStatus>
</Response>
</REMSResponse>
</Body>
</Message>
Notes:
V13
552
REMSResponse REMSResponse The transaction type: REMSResponse
Gender F Female
CLANCY, WI, 54999
777, US
CommunicationNumber 6152219800 The prescriber’s phone number (615) 221-9800. TE is the qualifier.
CAPSULE
V13
553
Structured Sig
ResponseStatus Approved
REMSCaseID A101 REMS Administrator-assigned identifier for this case.
REMSAuthorizationNumber BCDEFGH

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
V13
554
1.45 EXAMPLE 45: REMS – QUESTIONS – CLOSED

Prescriber checks REMS: The REMS Administrator needs the basic prescription information plus some questions answered before the prescribing for this REMS
medication can be approved. The prescriber answers the questions. This is the same examples as previous for illustration.
Transaction
Status (from REMSAdministrator)
REMSInitiationResponse (from REMS
Administrator)
V13
555
Status
After elapsed time
Status
REMS Administrator
Prescriber
After elapsed time
REMSRequest
Status
After elapsed time
REMSResponse
Status
V13
556
REMSInitiationRequest REMSInitiationResponse REMSRequest from REMSResponse from
from Prescriber from REMS Prescriber REMS Administrator
Administrator
<RxReferenceNumber>
<REMSAuthorizationNumber> Not applicable
<RxReferenceNumber>

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
V13
557
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
V13
558
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Sig>
</Sig>
V13
559
</Body>
</Message>
Notes:
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
V13
560
CAPSULE
PER MOUTH
CAPSULE
StructuredSig …

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
V13
561
From XXXXXX:REMS ID of REMS Administrator; REM means it is a REMS Administrator. This is

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
V13
562
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
<CountryCode>1</CountryCode>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
V13
563
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Sig>
</Sig>
<Response>
<ResponseStatus>
<Open>
<DeadlineForReply>
<Date>2015-11-01</Date>
</DeadlineForReply>
<QuestionSet>
<Header>
V13
564
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionText>I understand that JUXTAPID is indicated as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available, to reduce low-density lipoprotein
cholesterol (LDL-C), total cholesterol (TC), apolipoprotein B (apo B) and non-high-density lipoprotein cholesterol (non-HDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). I affirm that my patient has a
clinical or laboratory diagnosis consistent with HoFH. I understand that JUXTAPID has not been studied in pediatric patients less than 18 years. I attest that I have obtained the liver-related laboratory tests for this patient as
directed in JUXTAPIDs prescribing information.</QuestionText>
<QuestionType>
<Select>
<Choice>
</Choice>
<Choice>
</Choice>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</Open>
</ResponseStatus>
</Response>
</Body>
</Message>
Notes:
V13
565
ase
Gender F Female
CLANCY, WI, 54999
is shown in this
example.)
CAPSULE
V13
566
PER MOUTH
CAPSULE
ResponseStatus Open
QuestionSet
Header
the end-user.
result in delayed
determination for
Question 1
Question
V13
567
cholesterol (TC),
familial
(HoFH).
HoFH.
18 years.
Choice First choice
V13
568
<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:

V13
569
<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
V13
570
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
V13
571
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Request>
<SolicitedModel>
<DeadlineForReply>
</DeadlineForReply>
<QuestionSet>
<Header>
<PrimaryTelephone>
</PrimaryTelephone>
</Header>
<Question>
<QuestionText>I understand that JUXTAPID is indicated as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available, to reduce low-density lipoprotein cholesterol (LDL-
C), total cholesterol (TC), apolipoprotein B (apo B) and non-high-density lipoprotein cholesterol (non-HDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). I affirm that my patient has a clinical or laboratory
diagnosis consistent with HoFH. I understand that JUXTAPID has not been studied in pediatric patients less than 18 years. I attest that I have obtained the liver-related laboratory tests for this patient as directed in JUXTAPIDs
prescribing information.</QuestionText>
<QuestionType>
<Select>
<Choice>
</Choice>
V13
572
<Choice>
</Choice>
<Answer>
</Answer>
</Select>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</REMSRequest>
</Body>
</Message>
Notes:
MessageID 1234567 Prescriber trace number is used to link the original transaction (value in
RelatesToMessageID ABCDDDD REMS Administrator trace number is used to link the original transaction
(value in MessageID) from request to the response.
SecondaryIdentification PASSWORDR Password of the Clinic System directly to the REMS Administrator, if used,
ase
Gender F Female
V13
573
CLANCY, WI, 54999
is shown in this
example.)
CAPSULE
SigText 30 30 is the number of days supply.
Structured Sig
QuestionSet
Header
V13
574
the end-user.
result in delayed
determination for
Question 1
Question
cholesterol (TC),
familial
(HoFH).
HoFH.
18 years.
V13
575
Choice First choice
Answer

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
V13
576
Notes:

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<REMSResponse>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
V13
577
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
V13
578
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C25158</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>30</Value>
<Code>C48480</Code>
</Quantity>
<Response>
<ResponseStatus>
<Closed>
<ClosedReasonCode>BX</ClosedReasonCode>
<REMSNote>Prescribing not authorized due to laboratory test results</REMSNote>
</Closed>
</ResponseStatus>
</Response>
</REMSResponse>
</Body>
</Message>
V13
579
Notes:
REMSResponse REMSResponse The transaction type: REMSResponse
Gender F Female
CLANCY, WI, 54999
It is shown in this
example.)
777, US
CommunicationNumber 6152219800 The prescriber’s phone number (615) 221-9800. TE is the qualifier.
CAPSULE
V13
580
SigText 30 30 is the number of days supply.
Structured Sig
ResponseStatus Closed
ReasonCode Xx11
REMSNote Prescribing not
authorized due to
laboratory test results

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
V13
581
</Body>
</Message>
Notes:
1.46 EXAMPLE 46: REMS - NEWRX (FROM PRESCRIBER)

In this example a new prescription request is sent directly from the prescriber to the pharmacy. It is assumed there is a direct connection (dedicated line)
between the prescriber (clinic) and pharmacy. This example uses the same data as Example 1.
Transaction
V13
582
NewRx
Prescriber
Pharmacy
Status
NewRx from Prescriber

Field Name Value
<MessageID> 1234567
<RxReferenceNumber>
<MessageID> ABC11
<RxReferenceNumber>

<Header>
<Security>
<Sender>
V13
583
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<NewRx>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
V13
584
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugDescription>ELIQUIS 2.5MG</DrugDescription>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
<DrugDBCode>
</DrugDBCode>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
V13
585
<WrittenDate>
<Date>2015-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
<REMSPatientRiskCategory>AFNRP</REMSPatientRiskCategory>
</NewRx>
</Body>
</Message>
Notes:
SecondaryIdentification PASSWORDQ Password of the Clinic System directly to the Pharmacy, if used,
ase
dispensed.
Gender F Female
CLANCY, WI, 54999
V13
586
and Qualifier
DrugDescription ELIQUIS 2.5MG Drug prescribed is Eliquis 2.5mg.
240mg tablets.
DEASchedule
PrescriberCheckedREMS A Mandatory
REMSAuthorizationNumber ABCDEFGHIJ Optional
REMSPatientRiskCategory AFNRP Prescriber to send to the pharmacy. Optional

<Header>
V13
587
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
From 77777777:C This is the ID of the sender; C means it is a Clinic.
SecondaryIdentification PASSWORDQ Password of the Clinic System directly to the Pharmacy, if used,
ase
V13
588
1.47 EXAMPLE 47: REMS - PRESCRIPTION CHANGE REQUEST (VIA DIRECT CONNECT)
In this example, the pharmacy is requesting permission to change the original (new) prescription. The pharmacy is requesting to substitute generic from brand.
In this scenario the pharmacy and prescriber are directly connected (e.g. via dedicated line). Since the prescriber will probably not be able to answer the
change request real-time, the change response will come back to the pharmacy sometime in the future. This example uses the same data as Example 6, but
also includes the <RxFillIndicator>.
Transaction
...
RxChangeRequest
Status
Prescriber
Pharmacy
After elapsed time
RxChangeResponse
Status
V13
589
Pharmacy Prescriber

<RxReferenceNumber>
The trace number <MessageID> assigned by the prescribing system when they sent the NewRx was 1234567 (from Example 2).

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
V13
590
</Header>
<Body>
<RxChangeRequest>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
V13
591
<Name>
</Name>
<Address>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
</RxChangeRequest>
</Body>
V13
592
</Message>
Notes:
See detail in previous example.
sender. It must be the pharmacy ID.
ase
GENERIC?

<Header>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
V13
593
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
MessageID 22222 Prescriber trace number for this transmission.
RelatesToMessageID A55 Pharmacy trace number is to link the (MessageID) from request to the
response.
The prescriber systems sends an answer to the RxChangeRequest.

<Header>
<Security>
<Sender>
</Sender>
</Security>
<SenderSoftware>
</SenderSoftware>
</Header>
<Body>
<RxChangeResponse>
<Response>
<Approved></Approved>
V13
594
</Response>
<Patient>
<HumanPatient>
<Identification>
</Identification>
<Name>
</Name>
<Gender>F</Gender>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<City>CLANCY</City>
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NPI>7878787878</NPI>
</Identification>
<PrimaryTelephone>
</PrimaryTelephone>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Name>
</Name>
<Address>
V13
595
</Address>
<PrimaryTelephone>
</PrimaryTelephone>
</NonVeterinarian>
</Prescriber>
<DrugCoded>
<Strength>
<StrengthForm>
<Code>C42998</Code>
</StrengthForm>
<Code>C28253</Code>
</Strength>
</DrugCoded>
<Quantity>
<Value>60</Value>
<Code>C48542</Code>
</Quantity>
<WrittenDate>
<Date>2010-10-01</Date>
</WrittenDate>
<Sig>
</Sig>
<REMSPatientRiskCategory>AFNRP</REMSPatientRiskCategory>
</RxChangeResponse>
</Body>
</Message>
V13
596
Notes:
See detail above.
01T09:24:36
se
RxChangeResponse RxChangeRespon Prescription Change Response.
se
ResponseStatus Approved The request for substitution was approved by the prescriber.
REMSPatientID 8822333XX REMS ID for the patient.
RxFillIndicator ALL FILL The prescriber’s intent to receive RxFill Status Notifications for this
STATUSES patient/medication for all fill statuses except transferred.
EXCEPT
TRANSFERRED
PrescriberCheckedREMS A Mandatory
REMSAuthorizationNumber ABCDEFGHIJ Optional
REMSPatientRiskCategory AFNRP Prescriber to send to the pharmacy. Optional

<Header>
<SenderSoftware>
V13
597
</SenderSoftware>
</Header>
<Body>
<Status>
<Code>000</Code>
</Status>
</Body>
</Message>
Notes:
MessageID 8888 Pharmacy trace number for this transmission.
RelatesToMessageID 2291 Prescriber trace number is used to link the (MessageID) from request to the response.
V13
598
2. APPENDIX B. HISTORY OF IMPLEMENTATION GUIDE
CHANGES
2.1 VERSION 10
Version 10 is the initial release of the V2017071 SCRIPT Standard Examples Guide that provides
examples for messages within version 2017071 of the NCPDP SCRIPT Standard Implementation
Guide.
2.2 VERSION 11
Version 11 reflects the republication of V20170712 schema in addition to the following changes.
All examples except the Sig examples were updated to replace
<Message DatatypesVersion="!" TransportVersion="!" TransactionDomain="SCRIPT" TransactionVersion="!" StructuresVersion="!" ECLVersion="!"
xsi:noNamespaceSchemaLocation="samples.xsd" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
With
<Message DatatypesVersion="20170712" TransportVersion="20170712" TransactionDomain="SCRIPT" TransactionVersion="20170712"
StructuresVersion="20170712" ECLVersion="20170712" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" >
Compound Examples were updated to include the drug name in the DrugDescription element,
remove any old compound language in the notes, FinalCompoundPharmaceuticalDosageForm
values and notes, and StrengthForm notes.
2.3 VERSION 12
All examples except Sig examples were updated to replace
With
Replaced the Structured Sig Examples with 49 new and/or updated examples.
2.4 VERSION 13
All examples except Sig examples were updated to replace
With
V13
599

V2017071 SCRIPT STANDARD - Example - Guide

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National Council for Prescription Drug Programs

Phone: (480) 477-1000

Version 10 - July 2017

Example Data Elements

Physician’s Name MARK JONES

Pharmacy 1 ID 7701630 (NCPDP ID)

Pharmacy 2 ID 9801930 (NCPDP ID)

Pharmacy 3 ID 6601930 (NCPDP ID)

Status (no more mail)

NewRx (from Prescriber)

WrittenDate 2010-10-01 Date written 10/01/2010.

Status (from Mailbox)

NewRx from Prescriber

Status from Pharmacy

NewRx (from Prescriber)

Status (from Pharmacy)

Status (no more mail)

Status (no more mail)

<PrescriberOrderNumber> 110088 110088

<PrescriberOrderNumber> 110088 110088

NewRx with ReturnReceipt request (from Prescriber)

Status (from Mailbox)

GetMessage (from Pharmacy)

GetMessage (from Pharmacy)

Status (No More Mail, from Mailbox)

The pharmacy system then generates the Verify.

Verify for NewRx (from Pharmacy)

RxReferenceNumber Not sent. Not applicable.

Status to Verify (from Mailbox)

GetMessage (from Prescriber)

Verify for NewRx (from Mailbox)

RxReferenceNumber Not sent. Not applicable.

Status (no more mail)

After time elapse,

Pharmacy System Prescriber System

Status (no more mail)

<PrescriberOrderNumber> 110088 110088

<RxReferenceNumber> PH888 PH888

<PrescriberOrderNumber> 110088 110088

<RxReferenceNumber> PH888 PH888

RxChangeRequest (from Pharmacy)

WrittenDate 2010-10-01 Date Written 10/01/2010.

Status (from Mailbox)

RxChangeRequest (from Mailbox)

GetMessage (from Prescriber)

RxChangeResponse (from Prescriber)

Status (from Mailbox)

GetMessage (from Pharmacy)

RxChangeResponse (from Mailbox)

GetMessage (from Pharmacy)

Status (No More Mail, from Mailbox)

After elapsed time

<PrescriberOrderNumber> 110088 110088

<RxReferenceNumber> PH888 PH888

Status from Prescriber Status from Pharmacy

<MessageID> 22222 8888

RxChangeRequest (from Pharmacy)

Status (from Prescriber)