This Section describes the expected capabilities of the US Drug Formulary Server actor which is responsible for providing responses to the queries submitted by the US Drug Formulary Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Drug Formulary Server are defined.

Accesses the Descriptive Name of a FormularyDrug

Accesses the DrugPlan ID of a FormularyDrug

Accesses the DrugTier ID of a FormularyDrug

A health plan which contains links to administrative information, a list of formulary drugs covered under that plan, and a definition of drug tiers and their associated cost-sharing models.

Drug information which is part of a formulary including its RxNorm code, the PlanID of the formulary, information on prescribing limitations, and optionally drug classification and alternatives.

Generic or Branded Drugs included within the CoveragePlan’s formulary that could be prescribed as alternatives to the current FormularyDrug.

A description of the drug tiers used by the formulary and how those tiers implement copay and coinsurance amounts. Drug tiers do not have any inherent meaning that is consistent across all formularies. Rather, each tier is defined using this element.

A code that describes the coverage status of a drug in a health plan (e.g., preferred generic, specialty, etc.)

An email address for developers/public to report mistakes in the network and formulary data. FHIR URL type can be a web-url or an e-mail address.

The URL that goes directly to the formulary brochure for the specific standard plan or plan variation. If the formulary brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.

A Boolean indication of whether the formulary drug is available by mail order through the associated plan. The MailOrder value in FormularyDrug overrides the MailOrder value in DrugTierDefinition within the CoveragePlan.

The URL that goes directly to the plan brochure for the specific standard plan or plan variation. If the plan brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.

Array of Networks within a plan. If a network is not applicable for a plan, enter ‘Not applicable’ in the value string.

Unique, generated Plan ID number, such as HIOS ID for QHPs or Contract Number for Medicare Advantage Plans. Plan IDs must be unique within each organization that manages their formulary data.

Type of Plan ID. For all Marketplace plans this should be: HIOS-PLAN-ID. For all other plans this should be: OTHER-PLAN-ID.

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug.

A Boolean indication of whether the coverage plan imposes a quantity limit on this drug.

A Boolean indication of whether the coverage plan imposes a step therapy limit on this drug.

The URL that goes directly to the formulary brochure for the specific standard plan or plan variation. If the formulary brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.

Qualifier for coinsurance rate

Qualifier of copay amount

The drug tier of a particular medication in a health plan. The base set are examples. Each plan may have its own controlled vocabulary.

Types of pharmacies. Each payer will have its own controlled vocabulary.

Code for qualifier for coinsurance rate

Codes for qualifier of copay amount

Codes to represent the drug tier of a particular medication in a health plan. Base set are examples. Each plan may have its own controlled vocabulary.

Codes for types of Pharmacies. Each payer will have its own controlled vocabulary.

Sample Gold Health Plan

Sample Gold Health Plan

Sample Gold Health Plan

BluePreferred PPO HSA Silver $3,000

Doxepin HCl 5 % Topical Cream

Percocet 5 MG / 325 MG Oral Tablet

Percocet 5 MG / 325 MG Oral Tablet

Tylenol Extra Strength 500 MG Oral Tablet