DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1
DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1
This page is part of the US Drug Formulary (v2.1.0: STU2) 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
| Page standards status: Informative |
Generated Narrative: InsurancePlan PayerInsurancePlanA3002
Last updated: 2021-05-22 18:36:03+0000
Profile: Payer Insurance Plan
identifier: A3002
status: Active
type: Medicare Advantage
name: Sample Medicare Advantage Plan A3002
period: 2021-01-01 --> 2021-12-31
coverageArea: Location United States Area
contact
purpose: Patient
telecom: +1 (888) 555-3002
contact
purpose: Marketting
name: Sample Medicare Advantage Plan Marketing Website
contact
purpose: Summary
name: Sample Medicare Advantage Drug Plan Benefit Website
contact
purpose: Formulary
name: Sample Medicare Advantage Drug Plan Formulary Website
coverage
Formulary Reference: InsurancePlan Sample Medicare Advantage Part D Formulary D3002
type: drug policy
Benefits
Type Drug
plan
type: Drug
specificCost
category: 1 month in network retail
benefit
type: Generic
cost
type: Copay
qualifiers: Before Deductible
value: 10 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 1 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
IG © 2025+ HL7 International / Pharmacy. Package hl7.fhir.us.davinci-drug-formulary#2.1.0 based on FHIR 4.0.1. Generated 2025-02-26
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