PCS Overview

January 2026

Background: The current CPhA Pharmacy Claim Standard (CPhA PCS) was developed to provide orderly and efficient online processing of prescription drug claims. As drug benefits and pharmacy services have evolved, so must the Pharmacy Claims Standard (PCS). The intent is to support the needs of as wide a base of potential users as possible, while being flexible enough to change as new business or technology changes occur and to provide simple and easy implementation. In 2022, the Canadian Pharmacists Association, Neighbourhood Pharmacy Association of Canada and the Canadian Life and Health Insurance Association began a modernization and update process to ensure that the PCS standard continues to meet the needs of all users. The initiative is governed by a Steering Committee comprised of representatives from each partner organizations. In 2024, the PCS transitioned to the Canadian FHIR Pharmacy Claims Standard (FHIR PCS). FHIR – Fast Healthcare Interoperability Resources' standard, is a set of rules and specifications for exchanging electronic health care data. It is designed to be flexible and adaptable, so that it can be used in a wide range of settings and with different health care information systems.

Trial Use Designation and Moving Towards Implementation

During 2024-25 FHIR PCS resources met monthly with identified stakeholders that include software vendors, networks, pharmacy benefit managers, insurers and public plans across Canada to work through the proposed standard and identify any additional work or changes that there was agreement to include. Additional, coordination of benefits and ‘pharmacy services’ were identified as two areas that needed more focussed work. At the end of 2025, this work drew to a close. There will still be opportunities to fine-tune the standard, as Implementers conduct a full review of the proposed standard to ensure there is alignment with their own business requirements. The 90-day Trial Use Standard review period will take place from February 1st to April 30, 2026. Implementers will undertake their own reviews and submit any remaining comments or recommended updates to our Steering Committee for consideration.

Objectives of the FHIR PCS

To provide an updated, simplified and common claim format for all carriers and POS vendors across Canada to use. The goal is to provide real-time claims processing (data collection and payment) through a single device in the pharmacy which will link to all potential networks and carriers with which the community pharmacist may communicate. The messaging standard will facilitate data/information transmission required by federal, provincial or territorial regulations related to drug and pharmacy service utilization. It will also address gaps in clinical data in the current standard for the benefit of providers and payers. Additional claim data will help to reduce audits and clawbacks and will help to streamline work for pharmacy users. Lastly, it will minimize the need for additional standards, reporting solutions etc.

Frequently Asked Questions

1. What happens to the current pharmacy claims standard? What is the transition plan?
2. What areas of the Pharmacy Claims Standard are being reviewed and changed, and how will these functional changes benefit me?
3. What is the process to transition from the CPhA PCS to the FHIR PCS?
4. Who is involved in the development of the FHIR PCS?
5. What are the timelines for implementation?
6. How will the FHIR PCS be maintained?
7. Where will the FHIR-PCS reside?
8. What version of FHIR is the specification based on?
9. Does this specification align with other Canadian FHIR specifications?
   

1. What happens to the current pharmacy claims standard? What is the transition plan? The current version (v3) will continue to operate throughout a transition period to allow all stakeholders sufficient time to transition to the new standard. While no deadlines have been established, we recognize that this process may take several years. Version 3 will continue to be maintained and updated by CPhA throughout the transition period.
   

2. What areas of the Pharmacy Claims Standard are being reviewed and changed, and how will these functional changes benefit me?
   Key areas that will be addressed include: drug price limits, quantity decimal place limits, deferred payments, compounds, coordination of benefits, coding DINs, intervention/error codes, messages, DUR response messaging, special authorization information, and days' supply. The FHIR PCS also addresses pharmacy services. Some of the changes that we will see with the new FHIR-PCS are:

   1. Removing drug price limits: This will allow payers to accept electronic claims for more than the existing $9999.99 drug cost and $999.99 fee.
   2. Quantity Decimal Place Limits: Increases precision to track and record dosing on some medications.
   3. Coordination of Benefits: Improves visibility of payors adjudicating claims as a non-primary payor. New fields support inclusion of adjudication details from previous payors to be submitted in the claim request (BIN, amount paid, intervention codes)
   4. Deferred Payments: Adds support to response messages for deferred payments (insurer pays patient) which will enable pharmacy to submit the claim as a coordination of benefits. Also adds responses for delayed adjudication.
   5. Compounds: Removes the limit of submitting a single DIN. Allows pharmacy to submit a claim that indicates all ingredients in a compound. Improves visibility into active ingredient, ingredient list and quantities of each ingredient, allowing payors to correctly adjudicate the claim.
   6. Claim Response Details: Adds fields to claim response to indicate how much of cost/markup/fee cutbacks can be passed on to secondary third parties and to patient.
   7. Intervention Codes: Increases the number of intervention codes on a claim request and error codes on a response message to 10.
   8. Professional Services claim: This new claim type specifically addresses the data requirements for professional services. This reduces audits and claw backs and improve the user experience.
   9. Quebec claim requirements: New fields added to convey pricing requirements for Quebec
      
      

3. What is the process to transition from the CPhA PCS to the FHIR PCS? The transition will likely occur in two phases and must be coordinated between pharmacy software vendors, networks and adjudicators/payors. The MVP (Minimum Viable Product) phase, which all implementers must agree to implement as Phase 1, includes the implementation of FHIR message formats with all of the existing data that is used today in CPHA3 today.
   The goal of the MVP phase is to move implementers on to the new PCS FHIR standard with minimal effort by making the majority of new fields optional during this phase. Implementers may choose to send additional “optional” or “recommended” data (eg compound details) if they are able to do so, in order to realize the benefits. A complete list of new fields and functionality, along with the MVP status is included here.
   The second phase includes implementation of the remaining functionality as it applies to that organization’s business. For instance, if pharmacy services are not a part of benefits, they need not be implemented.
   

4. Who is involved in the development of the FHIR PCS?
   The development of the new FHIR PCS is a partnership between the Canadian Pharmacists Association, Neighbourhood Pharmacies Association of Canada and Canadian Life and Health Insurance Association and is governed by a Steering Committee comprised of representatives from each partner organizations. The FHIR PCS technical implementation is led by a resource expert in this area.
   

5. What is the support available for implementation by stakeholders?
   The Trial Use version is to be published early 2026 for a 90-day stakeholder review, and subsequently further discussion and/or updates made be made to the standard. That said, we expect there may be additional considerations as implementers start their own development. Our 3 organizations commit to continue to support the implementation and provide ongoing support throughout the life cycle of FHIR PCS.
   

6. How will the FHIR PCS be maintained?
   After implementation of the standard, stakeholders and users will be able to submit requests for changes. Implementation changes such as the addition of a new codes will be validated and can generally be accommodated in a timely manner. More complex changes will be collected and assessed for implementation by the Steering Committee.
   

7. Where will the FHIR-PCS reside?
   The specification will reside on the FHIR Simplifier platform. SIMPLIFIER.NET is a web based FHIR registry built by Firely (a healthcare IT company based in Amsterdam) that serves as the hosting platform for the Canadian FHIR Registry sponsored by Canada Health Infoway and other FHIR projects in Canada. The PCS implementation guide is available for viewing and allows stakeholders to download the implementation guide and FHIR artifacts.
   

8. What version of FHIR is the specification based on?
   This implementation Guide will be based on FHIR R4.
   

9. Does this specification align with other Canadian FHIR specifications?
   Yes, there will be alignment where possible to the R4 Canadian FHIR baseline profiles (Core-CA) though there is no formal dependency declared. This specification is also aligned where possible to PrescribeIT.