DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.1.0 - STU 1.1

This page is part of the US Drug Formulary (v1.1.0: 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 V3001 - XML Representation

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<List xmlns="http://hl7.org/fhir">
  <id value="CoveragePlanV3001"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-08-04T18:36:03.000+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: currentCode: drug policy</td></tr><tr><td></td></tr></table><table class="grid"><tr style="backgound-color: #eeeeee"><td><b>Items</b></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"/>
        </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </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"/>
          </coding>
        </valueCodeableConcept>
      </extension>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension">
    <valueUrl
              value="https://content.carefirst.com/sbc/D,$0/%20D,$0/%20D,$0/%20D,$0/%20D,$0B+"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension">
    <valueUrl value="http://url/to/formulary/information"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension">
    <valueUrl value="http://url/to/health/plan/information"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension">
    <valueUrl value="mailto: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="test"/>
  </identifier>
  <status value="current"/>
  <mode value="snapshot"/>
  <title value="Sample Gold Health Plan"/>
  <code>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <code value="DRUGPOL"/>
      <display value="drug policy"/>
    </coding>
  </code>
  <date value="2015-06-12"/>
</List>