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
<List xmlns="http://hl7.org/fhir"> <id value="covplanV1002"/> <meta> <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="BRAND"/> <display value="Brand"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MailOrder-extension"> <valueBoolean value="false"/> </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="20"/> </valueMoney> </extension> <extension url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoInsuranceRate-extension"> <valueDecimal value="0.2"/> </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="AFTER-DEDUCTIBLE"/> <display value="After Deductible"/> </coding> </valueCodeableConcept> </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="http://url/to/health/plan/information"/> </extension> <extension url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension"> <valueString value="http://url/to/health/plan/information"/> </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-EmailPlanContact-extension"> <valueString value="email@address.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="HIOS-PLAN-ID"/> </identifier> <status value="current"/> <mode value="snapshot"/> <title value="Sample Gold Health Plan"/> <date value="2015-06-12"/> <entry> <item> <reference value="MedicationKnowledge/formularydrugV1002"/> </item> </entry> </List>