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

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: Coverage Plan V1002 - JSON Representation

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{
  "resourceType" : "List",
  "id" : "covplanV1002",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<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-formularydrugV1002.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>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "drugTierID",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
                "code" : "brand",
                "display" : "Brand: Brand name drugs that cost more than ‘preferred brand’ drugs."
              }
            ]
          }
        },
        {
          "url" : "mailOrder",
          "valueBoolean" : false
        },
        {
          "extension" : [
            {
              "url" : "pharmacyType",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                    "code" : "1-month-in-retail",
                    "display" : "1 month in network retail: 1 Month Supply via in-network retail pharmacy."
                  }
                ]
              }
            },
            {
              "url" : "copayAmount",
              "valueMoney" : {
                "value" : 20
              }
            },
            {
              "url" : "coinsuranceRate",
              "valueDecimal" : 0.2
            },
            {
              "url" : "copayOption",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "after-deductible",
                    "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)."
                  }
                ]
              }
            },
            {
              "url" : "coinsuranceOption",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                    "code" : "after-deductible",
                    "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)."
                  }
                ]
              }
            }
          ],
          "url" : "costSharing"
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension",
      "valueString" : "http://url/to/health/plan/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
      "valueString" : "http://url/to/health/plan/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension",
      "valueString" : "http://url/to/formulary/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension",
      "valueString" : "email@address.com"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension",
      "valueString" : "PREFERRED"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension",
      "valueString" : "HIOS-PLAN-ID"
    }
  ],
  "identifier" : [
    {
      "value" : "HIOS-PLAN-ID"
    }
  ],
  "status" : "current",
  "mode" : "snapshot",
  "title" : "Sample Gold Health Plan",
  "date" : "2015-06-12",
  "entry" : [
    {
      "item" : {
        "reference" : "MedicationKnowledge/formularydrugV1002"
      }
    }
  ]
}