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

• Narrative Content
• XML
• JSON
• TTL

: Coverage Plan V3004t - XML Representation

Raw xml | Download

<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"><h2>BluePreferred PPO HSA Silver $3,000</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-cmsip9.html">Generated Summary: <span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 1000091}">doxepin HCl 5 % Topical Cream</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="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="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="10"/>
        </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="20"/>
        </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="20"/>
        </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-DrugTierDefinition-extension">
    <extension url="drugTierID">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
          <code value="zero-cost-share-preventative"/>
          <display
                   value="Zero cost-share preventative: Preventive medications and products available at no cost."/>
        </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="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="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>
    <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="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>
    <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="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>
    <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="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>
  </extension>
  <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="preferred-brand"/>
          <display value="Preferred Brand: Brand name drugs"/>
        </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="50"/>
        </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="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="50"/>
        </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="100"/>
        </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="100"/>
        </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-DrugTierDefinition-extension">
    <extension url="drugTierID">
      <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: Brand name drugs that cost more than ‘brand’ drugs."/>
        </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="70"/>
        </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="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="70"/>
        </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="140"/>
        </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="140"/>
        </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-DrugTierDefinition-extension">
    <extension url="drugTierID">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
          <code value="specialty"/>
          <display
                   value="Specialty: Drugs used to treat complex conditions like cancer and multiple sclerosis. They can be generic or brand name, and are typically the most expensive drugs on the formulary."/>
        </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="100"/>
        </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="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="100"/>
        </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="200"/>
        </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="200"/>
        </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="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>