DaVinci Payer Data Exchange (PDex) US Drug Formulary | STU2 Ballot
1.2.0 - STU2 Ballot
DaVinci Payer Data Exchange (PDex) US Drug Formulary | STU2 Ballot
1.2.0 - STU2 Ballot
This page is part of the US Drug Formulary (v1.2.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions 
Generated Narrative
Resource "PayerInsurancePlanA3004t" Updated "2021-08-04T18:36:03Z"
Profile: Payer Insurance Plan
identifier: id: A3004t
status: active
type: Medicare Advantage (Insurance Product Type#mediadv)
name: Sample Medicare Advantage Plan A3004t
period: 2021-01-01 --> 2021-12-31
coverageArea: Location/UnitedStatesLocation "United States Area"
contact
purpose: Patient (Contact entity type#PATINF)
telecom: +1 (888) 555-3004
contact
purpose: Plan Marketing Information (Codes for type of plan contact#MARKETING)
name: Sample Medicare Advantage Plan Marketing Website
contact
purpose: Plan Summary Information (Codes for type of plan contact#SUMMARY)
name: Sample Medicare Advantage Drug Plan Benefit Website
contact
purpose: Plan Formulary Information (Codes for type of plan contact#FORMULARY)
name: Sample Medicare Advantage Drug Plan Formulary Website
coverage
Formulary Reference: InsurancePlan/FormularyD3004t "Sample Medicare Advantage Part D Formulary D3004t"
type: drug policy (ActCode#DRUGPOL)
Benefits
- Type * Drug (Codes for type of plan#drug)
plan
type: Drug (Codes for type of plan#drug)
specificCost
category: 1 month in network retail (Codes for types of pharmacies#1-month-in-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 10 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for types of pharmacies#1-month-out-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 10 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for types of pharmacies#3-month-in-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 20 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for types of pharmacies#3-month-out-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 20 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month in network retail (Codes for types of pharmacies#1-month-in-retail)
benefit
type: Zero cost-share preventative (Codes for medication drug tiers in health plans#zero-cost-share-preventative)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: No Charge (Code for qualifier for coinsurance rate codes#no-charge)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for types of pharmacies#1-month-out-retail)
benefit
type: Zero cost-share preventative (Codes for medication drug tiers in health plans#zero-cost-share-preventative)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: No Charge (Code for qualifier for coinsurance rate codes#no-charge)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for types of pharmacies#3-month-in-retail)
benefit
type: Zero cost-share preventative (Codes for medication drug tiers in health plans#zero-cost-share-preventative)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: No Charge (Code for qualifier for coinsurance rate codes#no-charge)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for types of pharmacies#3-month-out-retail)
benefit
type: Zero cost-share preventative (Codes for medication drug tiers in health plans#zero-cost-share-preventative)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: No Charge (Code for qualifier for coinsurance rate codes#no-charge)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month in network retail (Codes for types of pharmacies#1-month-in-retail)
benefit
type: Preferred Brand (Codes for medication drug tiers in health plans#preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 50 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for types of pharmacies#1-month-out-retail)
benefit
type: Preferred Brand (Codes for medication drug tiers in health plans#preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 50 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for types of pharmacies#3-month-in-retail)
benefit
type: Preferred Brand (Codes for medication drug tiers in health plans#preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 100 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for types of pharmacies#3-month-out-retail)
benefit
type: Preferred Brand (Codes for medication drug tiers in health plans#preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 100 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month in network retail (Codes for types of pharmacies#1-month-in-retail)
benefit
type: Non-preferred Brand (Codes for medication drug tiers in health plans#non-preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 70 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for types of pharmacies#1-month-out-retail)
benefit
type: Non-preferred Brand (Codes for medication drug tiers in health plans#non-preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 70 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for types of pharmacies#3-month-in-retail)
benefit
type: Non-preferred Brand (Codes for medication drug tiers in health plans#non-preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 140 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for types of pharmacies#3-month-out-retail)
benefit
type: Non-preferred Brand (Codes for medication drug tiers in health plans#non-preferred-brand)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 140 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month in network retail (Codes for types of pharmacies#1-month-in-retail)
benefit
type: Specialty (Codes for medication drug tiers in health plans#specialty)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 100 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for types of pharmacies#1-month-out-retail)
benefit
type: Specialty (Codes for medication drug tiers in health plans#specialty)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 100 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for types of pharmacies#3-month-in-retail)
benefit
type: Specialty (Codes for medication drug tiers in health plans#specialty)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 200 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for types of pharmacies#3-month-out-retail)
benefit
type: Specialty (Codes for medication drug tiers in health plans#specialty)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes for qualifier of copay amount#no-charge)
value: 200 $ (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Code for qualifier for coinsurance rate codes#after-deductible)
value: 0 % (Details: UCUM code % = '%')
IG © 2021+ HL7 Pharmacy Working Group. Package hl7.fhir.us.davinci-drug-formulary#1.2.0 based on FHIR 4.0.1. Generated 2021-12-03
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