DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.0.1 - STU 1.0.1
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 
<List xmlns="http://hl7.org/fhir">
<id value="CoveragePlanV3002"/>
<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"><h2>Sample Gold Health Plan</h2><table class="clstu"><tr><td>Date: 2015-06-12Mode: snapshotStatus: current</td></tr><tr><td></td></tr></table><table class="grid"><tr style="backgound-color: #eeeeee"><td><b>Items</b></td></tr><tr><td><a href="MedicationKnowledge-FormularyDrugV3001.html">Generated Summary: <span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 1049640}">Percocet 5 MG / 325 MG Oral Tablet</span></a></td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension">
<extension url="drugTierID">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
<code value="generic"/>
<display
value="Generic: Commonly prescribed generic drugs that cost more than drugs in the ‘preferred generic’ tier."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="mailOrder">
<valueBoolean value="true"/>
</extension>
<extension url="costSharing">
<extension url="pharmacyType">
<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 in network retail: 1 Month Supply via in-network retail pharmacy."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="copayAmount">
<valueMoney>
<value value="10"/>
</valueMoney>
</extension>
<extension url="copayOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="before-deductible"/>
<display
value="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)."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="coinsuranceRate">
<valueDecimal value="1"/>
</extension>
<extension url="coinsuranceOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display
value="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)."/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension url="costSharing">
<extension url="pharmacyType">
<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 out of network retail: 1 Month Supply via out-of-network retail pharmacy."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="copayAmount">
<valueMoney>
<value value="0"/>
</valueMoney>
</extension>
<extension url="copayOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display
value="No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="coinsuranceRate">
<valueDecimal value="0"/>
</extension>
<extension url="coinsuranceOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display
value="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)."/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension url="costSharing">
<extension url="pharmacyType">
<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 in network retail: 3 Month Supply via in-network retail pharmacy."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="copayAmount">
<valueMoney>
<value value="0"/>
</valueMoney>
</extension>
<extension url="copayOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display
value="No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="coinsuranceRate">
<valueDecimal value="0"/>
</extension>
<extension url="coinsuranceOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display
value="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)."/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension url="costSharing">
<extension url="pharmacyType">
<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 out of network retail: 3 Month Supply via out-of-network retail pharmacy."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="copayAmount">
<valueMoney>
<value value="0"/>
</valueMoney>
</extension>
<extension url="copayOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
<code value="no-charge"/>
<display
value="No Charge: No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="coinsuranceRate">
<valueDecimal value="0"/>
</extension>
<extension url="coinsuranceOption">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
<code value="after-deductible"/>
<display
value="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)."/>
</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="test1"/>
</identifier>
<status value="current"/>
<mode value="snapshot"/>
<title value="Sample Gold Health Plan"/>
<date value="2015-06-12"/>
<entry>
<item>
<reference value="MedicationKnowledge/FormularyDrugV3001"/>
</item>
</entry>
</List>
IG © 2020+ HL7 Pharmacy Working Group. Package hl7.fhir.us.davinci-drug-formulary#1.0.1 based on FHIR 4.0.1. Generated 2020-12-21
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