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

• Narrative
• XML
• JSON
• Turtle

Example: CoveragePlanV3004t

@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:List;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "CoveragePlanV3004t"];
  fhir:Resource.meta [
     fhir:Meta.versionId [ fhir:value "1" ];
     fhir:Meta.lastUpdated [ fhir:value "2019-05-22T18:36:03.000+00:00"^^xsd:dateTime ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan>     ]
  ];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.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>"
  ];
  fhir:DomainResource.extension [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "GENERIC" ];
           fhir:Coding.display [ fhir:value "Generic" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "10"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "10"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "20"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "20"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 1;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "ZERO-COST-SHARE-PREVENTIVE" ];
           fhir:Coding.display [ fhir:value "Zero-cost share preventative" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 2;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "PREFERRED-BRAND" ];
           fhir:Coding.display [ fhir:value "Preferred Brand" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "50"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "50"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 3;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "NON-PREFERRED-BRAND" ];
           fhir:Coding.display [ fhir:value "Non-Preferred Brand" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "70"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "70"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "140"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "140"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 4;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "SPECIALTY" ];
           fhir:Coding.display [ fhir:value "Specialty" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "1 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-IN-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via in-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "200"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyType-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-MONTH-OUT-RETAIL" ];
             fhir:Coding.display [ fhir:value "3 Month Supply via out-of-network retail pharmacy" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayAmount-extension" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "200"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CopayOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "NO-CHARGE" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoinsuranceOption-extension" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "AFTER-DEDUCTIBLE" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CostSharing-extension" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 5;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension" ];
     fhir:Extension.valueString [ fhir:value "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+" ]
  ], [
     fhir:index 6;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension" ];
     fhir:Extension.valueString [ fhir:value "http://url/to/formulary/information" ]
  ], [
     fhir:index 7;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension" ];
     fhir:Extension.valueString [ fhir:value "http://url/to/formulary/information" ]
  ], [
     fhir:index 8;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension" ];
     fhir:Extension.valueString [ fhir:value "Patrick.Breen@carefirst.com" ]
  ], [
     fhir:index 9;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension" ];
     fhir:Extension.valueString [ fhir:value "PREFERRED" ]
  ], [
     fhir:index 10;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension" ];
     fhir:Extension.valueString [ fhir:value "HIOS-PLAN-ID" ]
  ];
  fhir:List.identifier [
     fhir:index 0;
     fhir:Identifier.value [ fhir:value "40308VA0240008" ]
  ];
  fhir:List.status [ fhir:value "current"];
  fhir:List.mode [ fhir:value "snapshot"];
  fhir:List.title [ fhir:value "BluePreferred PPO HSA Silver $3,000"];
  fhir:List.date [ fhir:value "2015-06-12"^^xsd:date];
  fhir:List.entry [
     fhir:index 0;
     fhir:List.entry.item [
       fhir:Reference.reference [ fhir:value "MedicationKnowledge/cmsip9" ]     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.