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 
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<lastUpdated value="2021-08-04T18:36:03.000+00:00"/>
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<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource "PayerInsurancePlanA3004t" Updated "2021-08-04T18:36:03Z" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-usdf-PayerInsurancePlan.html">Payer Insurance Plan</a></p></div><p><b>identifier</b>: id: A3004t</p><p><b>status</b>: active</p><p><b>type</b>: Medicare Advantage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1/CodeSystem-InsuranceProductTypeCS.html">Insurance Product Type</a>#mediadv)</span></p><p><b>name</b>: Sample Medicare Advantage Plan A3004t</p><p><b>period</b>: 2021-01-01 --> 2021-12-31</p><p><b>coverageArea</b>: <a href="Location-UnitedStatesLocation.html">Location/UnitedStatesLocation</a> "United States Area"</p><blockquote><p><b>contact</b></p><p><b>purpose</b>: Patient <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-contactentity-type.html">Contact entity type</a>#PATINF)</span></p><p><b>telecom</b>: <a href="tel:+1(888)555-3004">+1 (888) 555-3004</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Marketing Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PlanContactTypeCS.html">Codes for type of plan contact</a>#MARKETING)</span></p><p><b>name</b>: Sample Medicare Advantage Plan Marketing Website</p><p><b>telecom</b>: <a href="http://url/to/health/plan/information">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Summary Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PlanContactTypeCS.html">Codes for type of plan contact</a>#SUMMARY)</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Benefit Website</p><p><b>telecom</b>: <a href="http://url/to/health/plan/information">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Formulary Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PlanContactTypeCS.html">Codes for type of plan contact</a>#FORMULARY)</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Formulary Website</p><p><b>telecom</b>: <a href="http://url/to/health/plan/information">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>coverage</b></p><p><b>Formulary Reference</b>: <a href="InsurancePlan-FormularyD3004t.html">InsurancePlan/FormularyD3004t</a> "Sample Medicare Advantage Part D Formulary D3004t"</p><p><b>type</b>: drug policy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-v3-ActCode.html">ActCode</a>#DRUGPOL)</span></p><h3>Benefits</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td></tr><tr><td>*</td><td>Drug <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PlanTypeCS.html">Codes for type of plan</a>#drug)</span></td></tr></table></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: Drug <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PlanTypeCS.html">Codes for type of plan</a>#drug)</span></p><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 10 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 10 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 20 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 20 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 50 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 50 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 70 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 70 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 140 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-preferred Brand <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 140 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 200 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyTypeCS.html">Codes for types of pharmacies</a>#3-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-DrugTierCS.html">Codes for medication drug tiers in health plans</a>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CopayOptionCS.html">Codes for qualifier of copay amount</a>#no-charge)</span></p><p><b>value</b>: 200 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-BenefitCostTypeCS.html">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-CoinsuranceOptionCS.html">Code for qualifier for coinsurance rate codes</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>
</text>
<identifier>
<value value="A3004t"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS"/>
<code value="mediadv"/>
</coding>
</type>
<name value="Sample Medicare Advantage Plan A3004t"/>
<period>
<start value="2021-01-01"/>
<end value="2021-12-31"/>
</period>
<coverageArea>
<reference value="Location/UnitedStatesLocation"/>
</coverageArea>
<contact>
<purpose>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/contactentity-type"/>
<code value="PATINF"/>
</coding>
</purpose>
<telecom>
<system value="phone"/>
<value value="+1 (888) 555-3004"/>
</telecom>
</contact>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS"/>
<code value="MARKETING"/>
</coding>
</purpose>
<name>
<text value="Sample Medicare Advantage Plan Marketing Website"/>
</name>
<telecom>
<system value="url"/>
<value value="http://url/to/health/plan/information"/>
</telecom>
</contact>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS"/>
<code value="SUMMARY"/>
</coding>
</purpose>
<name>
<text value="Sample Medicare Advantage Drug Plan Benefit Website"/>
</name>
<telecom>
<system value="url"/>
<value value="http://url/to/health/plan/information"/>
</telecom>
</contact>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS"/>
<code value="FORMULARY"/>
</coding>
</purpose>
<name>
<text value="Sample Medicare Advantage Drug Plan Formulary Website"/>
</name>
<telecom>
<system value="url"/>
<value value="http://url/to/health/plan/information"/>
</telecom>
</contact>
<coverage>
<extension
url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension">
<valueReference>
<reference value="InsurancePlan/FormularyD3004t"/>
</valueReference>
</extension>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="DRUGPOL"/>
</coding>
</type>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanTypeCS"/>
<code value="drug"/>
</coding>
</type>
</benefit>
</coverage>
<plan>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanTypeCS"/>
<code value="drug"/>
<display value="Drug"/>
</coding>
</type>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-in-retail"/>
<display value="1 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="generic"/>
<display value="Generic"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="10"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-out-retail"/>
<display value="1 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="generic"/>
<display value="Generic"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="10"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="generic"/>
<display value="Generic"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="20"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-out-retail"/>
<display value="3 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="generic"/>
<display value="Generic"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="20"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-in-retail"/>
<display value="1 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="zero-cost-share-preventative"/>
<display value="Zero cost-share preventative"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-out-retail"/>
<display value="1 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="zero-cost-share-preventative"/>
<display value="Zero cost-share preventative"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="zero-cost-share-preventative"/>
<display value="Zero cost-share preventative"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-out-retail"/>
<display value="3 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="zero-cost-share-preventative"/>
<display value="Zero cost-share preventative"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-in-retail"/>
<display value="1 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="preferred-brand"/>
<display value="Preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="50"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-out-retail"/>
<display value="1 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="preferred-brand"/>
<display value="Preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="50"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="preferred-brand"/>
<display value="Preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="100"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-out-retail"/>
<display value="3 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="preferred-brand"/>
<display value="Preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="100"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-in-retail"/>
<display value="1 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="non-preferred-brand"/>
<display value="Non-preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="70"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-out-retail"/>
<display value="1 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="non-preferred-brand"/>
<display value="Non-preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="70"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="non-preferred-brand"/>
<display value="Non-preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="140"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-out-retail"/>
<display value="3 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="non-preferred-brand"/>
<display value="Non-preferred Brand"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="140"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-in-retail"/>
<display value="1 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="specialty"/>
<display value="Specialty"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="100"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="1-month-out-retail"/>
<display value="1 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="specialty"/>
<display value="Specialty"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="100"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="specialty"/>
<display value="Specialty"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="200"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
<code value="3-month-out-retail"/>
<display value="3 month out of network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="specialty"/>
<display value="Specialty"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="200"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
</plan>
</InsurancePlan>
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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