US Drug Formulary STU Ballot

This page is part of the US Drug Formulary (v0.1.0: STU 1 Draft) 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

Example: CoveragePlanV3001

{
  "resourceType" : "List",
  "id" : "CoveragePlanV3001",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2019-05-22T18:36:03.000+00:00",
    "profile" : [
      "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>*** CoveragePlan Example #1 (Reference to MedicationKnowledge) ***</b></p><p><b>id</b>: covplanV2001</p><p><b>Plan Name</b>: Sample Gold Health Plan</p><p><b>Drug Product</b>: <i>(Generated Detail from id - formularydrugV1001):</i> Acetaminophen 325 MG / Oxycodone Hydrochloride 5 MG Oral Tablet [Percocet]</p><p><b>Status</b>: current </p><p><b>Drug Tier ID</b>: Brand </p><p><b>Mail order</b>: false </p><p><b>Pharmacy type</b>: 1-MONTH-IN-RETAIL</p><p><b>Copay Amount</b>: 20.0</p><p><b>Copay option</b>: AFTER-DEDUCTIBLE</p><p><b>Coinsurance rate</b>: 0.20</p><p><b>Coinsurance option</b>: AFTER-DEDUCTIBLE</p></div>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
                "code" : "GENERIC",
                "display" : "Generic"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension",
          "valueBoolean" : true
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                    "code" : "1-MONTH-IN-RETAIL",
                    "display" : "1 Month Supply via in-network retail pharmacy"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension",
              "valueMoney" : {
                "value" : 0
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "NO-CHARGE",
                    "display" : "No Charge"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension",
              "valueDecimal" : 0
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                    "code" : "AFTER-DEDUCTIBLE",
                    "display" : "After Deductible"
                  }
                ]
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                    "code" : "1-MONTH-OUT-RETAIL",
                    "display" : "1 Month Supply via out-of-network retail pharmacy"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension",
              "valueMoney" : {
                "value" : 0
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "NO-CHARGE",
                    "display" : "No Charge"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension",
              "valueDecimal" : 0
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                    "code" : "AFTER-DEDUCTIBLE",
                    "display" : "After Deductible"
                  }
                ]
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                    "code" : "3-MONTH-IN-RETAIL",
                    "display" : "3 Month Supply via in-network retail pharmacy"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension",
              "valueMoney" : {
                "value" : 0
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "NO-CHARGE",
                    "display" : "No Charge"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension",
              "valueDecimal" : 0
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                    "code" : "AFTER-DEDUCTIBLE",
                    "display" : "After Deductible"
                  }
                ]
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                    "code" : "3-MONTH-OUT-RETAIL",
                    "display" : "3 Month Supply via out-of-network retail pharmacy"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension",
              "valueMoney" : {
                "value" : 0
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "NO-CHARGE",
                    "display" : "No Charge"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension",
              "valueDecimal" : 0
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                    "code" : "AFTER-DEDUCTIBLE",
                    "display" : "After Deductible"
                  }
                ]
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension"
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension",
      "valueString" : "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension",
      "valueString" : "http://url/to/formulary/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
      "valueString" : "http://url/to/health/plan/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension",
      "valueString" : "Patrick.Breen@carefirst.com"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension",
      "valueString" : "PREFERRED"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension",
      "valueString" : "HIOS-PLAN-ID"
    }
  ],
  "identifier" : [
    {
      "value" : "test"
    }
  ],
  "status" : "current",
  "mode" : "snapshot",
  "title" : "Sample Gold Health Plan",
  "date" : "2015-06-12",
  "entry" : [
    {
      "item" : {
        "reference" : "MedicationKnowledge/FormularyDrugV3001"
      }
    }
  ]
}