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 V1002

Sample Gold Health Plan

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

Notes:

FieldValue
resourceType "List"
meta.profile[0]"http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
id "covplanV1002"
identifier[0].value HIOS-PLAN-ID
status "current"
mode "snapshot"
title "Sample Gold Health Plan"
date "2015-06-12"
entry[0].item.reference "MedicationKnowledge/formularydrugV1002"
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 #brand
extension[0].extension[0].valueCodeableConcept.coding[0].display "Brand: Brand name drugs that cost more than ‘preferred brand’ drugs."
extension[0].extension[1].url "mailOrder"
extension[0].extension[1].valueBoolean "false"
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 20
extension[0].extension[2].extension[2].url "coinsuranceRate"
extension[0].extension[2].extension[2].valueDecimal "0.2"
extension[0].extension[2].extension[3].url "copayOption"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].display "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the copay (this indicates that this benefit is subject to the deductible)."
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[1].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension"
extension[1].valueString "http://url/to/health/plan/information"
extension[2].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension"
extension[2].valueString "http://url/to/health/plan/information"
extension[3].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-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 "email@address.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"