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: CoveragePlanV3004t


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