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

: Coverage Plan V1002 - XML Representation

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<List xmlns="http://hl7.org/fhir">
  <id value="covplanV1002"/>
  <meta>
    <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-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>
  </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="brand"/>
          <display
                   value="Brand: Brand name drugs that cost more than ‘preferred brand’ drugs."/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="mailOrder">
      <valueBoolean value="false"/>
    </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="20"/>
        </valueMoney>
      </extension>
      <extension url="coinsuranceRate">
        <valueDecimal value="0.2"/>
      </extension>
      <extension url="copayOption">
        <valueCodeableConcept>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
            <code value="after-deductible"/>
            <display
                     value="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)."/>
          </coding>
        </valueCodeableConcept>
      </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="http://url/to/health/plan/information"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension">
    <valueString value="http://url/to/health/plan/information"/>
  </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-EmailPlanContact-extension">
    <valueString value="email@address.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="HIOS-PLAN-ID"/>
  </identifier>
  <status value="current"/>
  <mode value="snapshot"/>
  <title value="Sample Gold Health Plan"/>
  <date value="2015-06-12"/>
  <entry>
    <item>
      <reference value="MedicationKnowledge/formularydrugV1002"/>
    </item>
  </entry>
</List>