DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.1 - STU 2 United States of America flag

This page is part of the US Drug Formulary (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: PayerInsurancePlanA1002 - TTL Representation

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:InsurancePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "PayerInsurancePlanA1002"] ; # 
  fhir:meta [
fhir:lastUpdated [ fhir:v "2021-08-22T18:36:03.000+00:00"^^xsd:dateTime ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: InsurancePlan</b><a name=\"PayerInsurancePlanA1002\"> </a></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 InsurancePlan &quot;PayerInsurancePlanA1002&quot; Updated &quot;2021-08-22 18:36:03+0000&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-PayerInsurancePlan.html\">Payer Insurance Plan</a></p></div><p><b>identifier</b>: id: A1002</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/STU1.1/CodeSystem-InsuranceProductTypeCS.html\">Insurance Product Type</a>#mediadv)</span></p><p><b>name</b>: Sample Medicare Advantage Plan A1002</p><p><b>period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>coverageArea</b>: <a href=\"Location-StateOfCTLocation.html\">Location/StateOfCTLocation</a> &quot;State of CT Area&quot;</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/5.3.0/CodeSystem-contactentity-type.html\">Contact entity type</a>#PATINF)</span></p><p><b>telecom</b>: <a href=\"tel:+1(888)555-1002\">+1 (888) 555-1002</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-TEMPORARY-TRIAL-USE.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-TEMPORARY-TRIAL-USE.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-TEMPORARY-TRIAL-USE.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-FormularyD1002.html\">InsurancePlan/FormularyD1002</a> &quot;Sample Medicare Advantage Part D Formulary D1002&quot;</p><p><b>type</b>: drug policy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ActCode.html\">ActCode</a>#DRUGPOL)</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>Drug <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-insurance-plan-type.html\">Insurance plan type</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=\"http://terminology.hl7.org/5.3.0/CodeSystem-insurance-plan-type.html\">Insurance plan type</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-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for pharmacy benefit types</a>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Brand <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-DrugTierCS-TEMPORARY-TRIAL-USE.html\">Codes for medication drug tiers in health plans</a>#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-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 20 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</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-TEMPORARY-TRIAL-USE.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-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 20 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>"
  ] ; # 
  fhir:identifier ( [
fhir:value [ fhir:v "A1002" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type ( [
    ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "mediadv" ]     ] )
  ] ) ; # 
  fhir:name [ fhir:v "Sample Medicare Advantage Plan A1002"] ; # 
  fhir:period [
fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-12-31"^^xsd:date ]
  ] ; # 
  fhir:coverageArea ( [
fhir:reference [ fhir:v "Location/StateOfCTLocation" ]
  ] ) ; # 
  fhir:contact ( [
fhir:purpose [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/contactentity-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "PATINF" ]       ] )     ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "phone" ] ;
fhir:value [ fhir:v "+1 (888) 555-1002" ]     ] )
  ] [
fhir:purpose [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "MARKETING" ]       ] )     ] ;
fhir:name [
fhir:text [ fhir:v "Sample Medicare Advantage Plan Marketing Website" ]     ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://url/to/health/plan/information" ]     ] )
  ] [
fhir:purpose [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "SUMMARY" ]       ] )     ] ;
fhir:name [
fhir:text [ fhir:v "Sample Medicare Advantage Drug Plan Benefit Website" ]     ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://url/to/health/plan/information" ]     ] )
  ] [
fhir:purpose [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FORMULARY" ]       ] )     ] ;
fhir:name [
fhir:text [ fhir:v "Sample Medicare Advantage Drug Plan Formulary Website" ]     ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://url/to/health/plan/information" ]     ] )
  ] ) ; # 
  fhir:coverage ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "InsurancePlan/FormularyD1002" ]       ]     ] ) ;
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "DRUGPOL" ]       ] )     ] ;
    ( fhir:benefit [
fhir:type [
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/insurance-plan-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "drug" ] ;
fhir:display [ fhir:v "Drug" ]         ] )       ]     ] )
  ] ) ; # 
  fhir:plan ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/insurance-plan-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "drug" ] ;
fhir:display [ fhir:v "Drug" ]       ] )     ] ;
    ( fhir:specificCost [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1-month-in-retail" ] ;
fhir:display [ fhir:v "1 month in network retail" ]         ] )       ] ;
      ( fhir:benefit [
fhir:type [
          ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "brand" ] ;
fhir:display [ fhir:v "Brand" ]           ] )         ] ;
        ( fhir:cost [
fhir:type [
            ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "copay" ] ;
fhir:display [ fhir:v "Copay" ]             ] )           ] ;
          ( fhir:qualifiers [
            ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "after-deductible" ] ;
fhir:display [ fhir:v "After Deductible" ]             ] )           ] ) ;
fhir:value [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:unit [ fhir:v "$" ] ;
fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ;
fhir:code [ fhir:v "USD" ]           ]         ] [
fhir:type [
            ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Coinsurance" ]             ] )           ] ;
          ( fhir:qualifiers [
            ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "after-deductible" ] ;
fhir:display [ fhir:v "After Deductible" ]             ] )           ] ) ;
fhir:value [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "%" ]           ]         ] )       ] )     ] )
  ] ) . #