DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.0.1 - STU 1.0.1

This page is part of the US Drug Formulary (v1.0.1: STU 1) 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 List: Coverage Plan V3002

Sample Gold Health Plan

Date: 2015-06-12Mode: snapshotStatus: current
Items
Generated Summary: Percocet 5 MG / 325 MG Oral Tablet

Notes:

FieldValue
resourceType "List"
id "CoveragePlanV3002"
identifier[0].value test1
meta.versionId "1"
meta.lastUpdated "2019-05-22T18:36:03.000+00:00"
meta.profile[0]"http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
extension[0].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
extension[0].extension[0].url "drugTierID"
extension[0].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"
extension[0].extension[0].valueCodeableConcept.coding[0].code #generic
extension[0].extension[0].valueCodeableConcept.coding[0].display "Generic: Commonly prescribed generic drugs that cost more than drugs in the ‘preferred generic’ tier."
extension[0].extension[1].url "mailOrder"
extension[0].extension[1].valueBoolean "true"
extension[0].extension[2].url "costSharing"
extension[0].extension[2].extension[0].url "pharmacyType"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].code #1-month-in-retail
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].display "1 month in network retail: 1 Month Supply via in-network retail pharmacy."
extension[0].extension[2].extension[1].url "copayAmount"
extension[0].extension[2].extension[1].valueMoney.value 10
extension[0].extension[2].extension[2].url "copayOption"
extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].code #before-deductible
extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].display "Before Deductible: The consumer first pays the copay, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible)."
extension[0].extension[2].extension[3].url "coinsuranceRate"
extension[0].extension[2].extension[3].valueDecimal "1"
extension[0].extension[2].extension[4].url "coinsuranceOption"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].display "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer pays the coinsurance portion of allowed charges (this indicates that this benefit is subject to the deductible)."
extension[0].extension[3].url "costSharing"
extension[0].extension[3].extension[0].url "pharmacyType"
extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].code #1-month-out-retail
extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].display "1 month out of network retail: 1 Month Supply via out-of-network retail pharmacy."
extension[0].extension[3].extension[1].url "copayAmount"
extension[0].extension[3].extension[1].valueMoney.value 0
extension[0].extension[3].extension[2].url "copayOption"
extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].code #no-charge
extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].display "No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."
extension[0].extension[3].extension[3].url "coinsuranceRate"
extension[0].extension[3].extension[3].valueDecimal "0"
extension[0].extension[3].extension[4].url "coinsuranceOption"
extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].display "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer pays the coinsurance portion of allowed charges (this indicates that this benefit is subject to the deductible)."
extension[0].extension[4].url "costSharing"
extension[0].extension[4].extension[0].url "pharmacyType"
extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].code #3-month-in-retail
extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].display "3 month in network retail: 3 Month Supply via in-network retail pharmacy."
extension[0].extension[4].extension[1].url "copayAmount"
extension[0].extension[4].extension[1].valueMoney.value 0
extension[0].extension[4].extension[2].url "copayOption"
extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].code #no-charge
extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].display "No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."
extension[0].extension[4].extension[3].url "coinsuranceRate"
extension[0].extension[4].extension[3].valueDecimal "0"
extension[0].extension[4].extension[4].url "coinsuranceOption"
extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].display "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer pays the coinsurance portion of allowed charges (this indicates that this benefit is subject to the deductible)."
extension[0].extension[5].url "costSharing"
extension[0].extension[5].extension[0].url "pharmacyType"
extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].code #3-month-out-retail
extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].display "3 month out of network retail: 3 Month Supply via out-of-network retail pharmacy."
extension[0].extension[5].extension[1].url "copayAmount"
extension[0].extension[5].extension[1].valueMoney.value 0
extension[0].extension[5].extension[2].url "copayOption"
extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].code #no-charge
extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].display "No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."
extension[0].extension[5].extension[3].url "coinsuranceRate"
extension[0].extension[5].extension[3].valueDecimal "0"
extension[0].extension[5].extension[4].url "coinsuranceOption"
extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].display "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer pays the coinsurance portion of allowed charges (this indicates that this benefit is subject to the deductible)."
extension[1].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension"
extension[1].valueString "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+"
extension[2].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension"
extension[2].valueString "http://url/to/formulary/information"
extension[3].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension"
extension[3].valueString "http://url/to/formulary/information"
extension[4].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension"
extension[4].valueString "Patrick.Breen@carefirst.com"
extension[5].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension"
extension[5].valueString "PREFERRED"
extension[6].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension"
extension[6].valueString "HIOS-PLAN-ID"
status "current"
mode "snapshot"
title "Sample Gold Health Plan"
date "2015-06-12"
entry[0].item.reference "MedicationKnowledge/FormularyDrugV3001"