DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.1.0 - STU 1.1
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 
| Date: 2015-06-12Mode: snapshotStatus: currentCode: drug policy |
| Items |
| Field | Value |
| resourceType | "List" |
| id | "CoveragePlanV3004t" |
| identifier[0].value | 40308VA0240008 |
| meta.versionId | "1" |
| meta.lastUpdated | "2019-05-22T18:36:03.000+00:00" |
| meta.profile[0] | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan" |
| 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 | #generic |
| extension[0].extension[0].valueCodeableConcept.coding[0].display | "Generic" |
| extension[0].extension[1].url | "mailOrder" |
| extension[0].extension[1].valueBoolean | "true" |
| 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" |
| extension[0].extension[2].extension[1].url | "copayAmount" |
| extension[0].extension[2].extension[1].valueMoney.value | 10 |
| extension[0].extension[2].extension[2].url | "copayOption" |
| extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[0].extension[2].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[0].extension[2].extension[3].url | "coinsuranceRate" |
| extension[0].extension[2].extension[3].valueDecimal | "0" |
| 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" |
| extension[0].extension[3].url | "costSharing" |
| extension[0].extension[3].extension[0].url | "pharmacyType" |
| extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].code | #1-month-out-retail |
| extension[0].extension[3].extension[0].valueCodeableConcept.coding[0].display | "1 month out of network retail" |
| extension[0].extension[3].extension[1].url | "copayAmount" |
| extension[0].extension[3].extension[1].valueMoney.value | 10 |
| extension[0].extension[3].extension[2].url | "copayOption" |
| extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[0].extension[3].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[0].extension[3].extension[3].url | "coinsuranceRate" |
| extension[0].extension[3].extension[3].valueDecimal | "0" |
| extension[0].extension[3].extension[4].url | "coinsuranceOption" |
| extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[0].extension[3].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[0].extension[4].url | "costSharing" |
| extension[0].extension[4].extension[0].url | "pharmacyType" |
| extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].code | #3-month-in-retail |
| extension[0].extension[4].extension[0].valueCodeableConcept.coding[0].display | "3 month in network retail" |
| extension[0].extension[4].extension[1].url | "copayAmount" |
| extension[0].extension[4].extension[1].valueMoney.value | 20 |
| extension[0].extension[4].extension[2].url | "copayOption" |
| extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[0].extension[4].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[0].extension[4].extension[3].url | "coinsuranceRate" |
| extension[0].extension[4].extension[3].valueDecimal | "0" |
| extension[0].extension[4].extension[4].url | "coinsuranceOption" |
| extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[0].extension[4].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[0].extension[5].url | "costSharing" |
| extension[0].extension[5].extension[0].url | "pharmacyType" |
| extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].code | #3-month-out-retail |
| extension[0].extension[5].extension[0].valueCodeableConcept.coding[0].display | "3 month out of network retail" |
| extension[0].extension[5].extension[1].url | "copayAmount" |
| extension[0].extension[5].extension[1].valueMoney.value | 20 |
| extension[0].extension[5].extension[2].url | "copayOption" |
| extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[0].extension[5].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[0].extension[5].extension[3].url | "coinsuranceRate" |
| extension[0].extension[5].extension[3].valueDecimal | "0" |
| extension[0].extension[5].extension[4].url | "coinsuranceOption" |
| extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[0].extension[5].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[1].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" |
| extension[1].extension[0].url | "drugTierID" |
| extension[1].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" |
| extension[1].extension[0].valueCodeableConcept.coding[0].code | #zero-cost-share-preventative |
| extension[1].extension[0].valueCodeableConcept.coding[0].display | "Zero cost-share preventative" |
| extension[1].extension[1].url | "mailOrder" |
| extension[1].extension[1].valueBoolean | "true" |
| extension[1].extension[2].url | "costSharing" |
| extension[1].extension[2].extension[0].url | "pharmacyType" |
| extension[1].extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[1].extension[2].extension[0].valueCodeableConcept.coding[0].code | #1-month-in-retail |
| extension[1].extension[2].extension[0].valueCodeableConcept.coding[0].display | "1 month in network retail" |
| extension[1].extension[2].extension[1].url | "copayAmount" |
| extension[1].extension[2].extension[1].valueMoney.value | 0 |
| extension[1].extension[2].extension[2].url | "copayOption" |
| extension[1].extension[2].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[1].extension[2].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[2].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[2].extension[3].url | "coinsuranceRate" |
| extension[1].extension[2].extension[3].valueDecimal | "0" |
| extension[1].extension[2].extension[4].url | "coinsuranceOption" |
| extension[1].extension[2].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[1].extension[2].extension[4].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[2].extension[4].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[3].url | "costSharing" |
| extension[1].extension[3].extension[0].url | "pharmacyType" |
| extension[1].extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[1].extension[3].extension[0].valueCodeableConcept.coding[0].code | #1-month-out-retail |
| extension[1].extension[3].extension[0].valueCodeableConcept.coding[0].display | "1 month out of network retail" |
| extension[1].extension[3].extension[1].url | "copayAmount" |
| extension[1].extension[3].extension[1].valueMoney.value | 0 |
| extension[1].extension[3].extension[2].url | "copayOption" |
| extension[1].extension[3].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[1].extension[3].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[3].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[3].extension[3].url | "coinsuranceRate" |
| extension[1].extension[3].extension[3].valueDecimal | "0" |
| extension[1].extension[3].extension[4].url | "coinsuranceOption" |
| extension[1].extension[3].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[1].extension[3].extension[4].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[3].extension[4].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[4].url | "costSharing" |
| extension[1].extension[4].extension[0].url | "pharmacyType" |
| extension[1].extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[1].extension[4].extension[0].valueCodeableConcept.coding[0].code | #3-month-in-retail |
| extension[1].extension[4].extension[0].valueCodeableConcept.coding[0].display | "3 month in network retail" |
| extension[1].extension[4].extension[1].url | "copayAmount" |
| extension[1].extension[4].extension[1].valueMoney.value | 0 |
| extension[1].extension[4].extension[2].url | "copayOption" |
| extension[1].extension[4].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[1].extension[4].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[4].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[4].extension[3].url | "coinsuranceRate" |
| extension[1].extension[4].extension[3].valueDecimal | "0" |
| extension[1].extension[4].extension[4].url | "coinsuranceOption" |
| extension[1].extension[4].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[1].extension[4].extension[4].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[4].extension[4].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[5].url | "costSharing" |
| extension[1].extension[5].extension[0].url | "pharmacyType" |
| extension[1].extension[5].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[1].extension[5].extension[0].valueCodeableConcept.coding[0].code | #3-month-out-retail |
| extension[1].extension[5].extension[0].valueCodeableConcept.coding[0].display | "3 month out of network retail" |
| extension[1].extension[5].extension[1].url | "copayAmount" |
| extension[1].extension[5].extension[1].valueMoney.value | 0 |
| extension[1].extension[5].extension[2].url | "copayOption" |
| extension[1].extension[5].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[1].extension[5].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[5].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[1].extension[5].extension[3].url | "coinsuranceRate" |
| extension[1].extension[5].extension[3].valueDecimal | "0" |
| extension[1].extension[5].extension[4].url | "coinsuranceOption" |
| extension[1].extension[5].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[1].extension[5].extension[4].valueCodeableConcept.coding[0].code | #no-charge |
| extension[1].extension[5].extension[4].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[2].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" |
| extension[2].extension[0].url | "drugTierID" |
| extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" |
| extension[2].extension[0].valueCodeableConcept.coding[0].code | #preferred-brand |
| extension[2].extension[0].valueCodeableConcept.coding[0].display | "Preferred Brand" |
| extension[2].extension[1].url | "mailOrder" |
| extension[2].extension[1].valueBoolean | "true" |
| extension[2].extension[2].url | "costSharing" |
| extension[2].extension[2].extension[0].url | "pharmacyType" |
| extension[2].extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[2].extension[2].extension[0].valueCodeableConcept.coding[0].code | #1-month-in-retail |
| extension[2].extension[2].extension[0].valueCodeableConcept.coding[0].display | "1 month in network retail" |
| extension[2].extension[2].extension[1].url | "copayAmount" |
| extension[2].extension[2].extension[1].valueMoney.value | 50 |
| extension[2].extension[2].extension[2].url | "copayOption" |
| extension[2].extension[2].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[2].extension[2].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[2].extension[2].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[2].extension[2].extension[3].url | "coinsuranceRate" |
| extension[2].extension[2].extension[3].valueDecimal | "0" |
| extension[2].extension[2].extension[4].url | "coinsuranceOption" |
| extension[2].extension[2].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[2].extension[2].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[2].extension[2].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[2].extension[3].url | "costSharing" |
| extension[2].extension[3].extension[0].url | "pharmacyType" |
| extension[2].extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[2].extension[3].extension[0].valueCodeableConcept.coding[0].code | #1-month-out-retail |
| extension[2].extension[3].extension[0].valueCodeableConcept.coding[0].display | "1 month out of network retail" |
| extension[2].extension[3].extension[1].url | "copayAmount" |
| extension[2].extension[3].extension[1].valueMoney.value | 50 |
| extension[2].extension[3].extension[2].url | "copayOption" |
| extension[2].extension[3].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[2].extension[3].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[2].extension[3].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[2].extension[3].extension[3].url | "coinsuranceRate" |
| extension[2].extension[3].extension[3].valueDecimal | "0" |
| extension[2].extension[3].extension[4].url | "coinsuranceOption" |
| extension[2].extension[3].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[2].extension[3].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[2].extension[3].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[2].extension[4].url | "costSharing" |
| extension[2].extension[4].extension[0].url | "pharmacyType" |
| extension[2].extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[2].extension[4].extension[0].valueCodeableConcept.coding[0].code | #3-month-in-retail |
| extension[2].extension[4].extension[0].valueCodeableConcept.coding[0].display | "3 month in network retail" |
| extension[2].extension[4].extension[1].url | "copayAmount" |
| extension[2].extension[4].extension[1].valueMoney.value | 100 |
| extension[2].extension[4].extension[2].url | "copayOption" |
| extension[2].extension[4].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[2].extension[4].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[2].extension[4].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[2].extension[4].extension[3].url | "coinsuranceRate" |
| extension[2].extension[4].extension[3].valueDecimal | "0" |
| extension[2].extension[4].extension[4].url | "coinsuranceOption" |
| extension[2].extension[4].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[2].extension[4].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[2].extension[4].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[2].extension[5].url | "costSharing" |
| extension[2].extension[5].extension[0].url | "pharmacyType" |
| extension[2].extension[5].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[2].extension[5].extension[0].valueCodeableConcept.coding[0].code | #3-month-out-retail |
| extension[2].extension[5].extension[0].valueCodeableConcept.coding[0].display | "3 month out of network retail" |
| extension[2].extension[5].extension[1].url | "copayAmount" |
| extension[2].extension[5].extension[1].valueMoney.value | 100 |
| extension[2].extension[5].extension[2].url | "copayOption" |
| extension[2].extension[5].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[2].extension[5].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[2].extension[5].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[2].extension[5].extension[3].url | "coinsuranceRate" |
| extension[2].extension[5].extension[3].valueDecimal | "0" |
| extension[2].extension[5].extension[4].url | "coinsuranceOption" |
| extension[2].extension[5].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[2].extension[5].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[2].extension[5].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[3].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" |
| extension[3].extension[0].url | "drugTierID" |
| extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" |
| extension[3].extension[0].valueCodeableConcept.coding[0].code | #non-preferred-brand |
| extension[3].extension[0].valueCodeableConcept.coding[0].display | "Non-preferred Brand" |
| extension[3].extension[1].url | "mailOrder" |
| extension[3].extension[1].valueBoolean | "true" |
| extension[3].extension[2].url | "costSharing" |
| extension[3].extension[2].extension[0].url | "pharmacyType" |
| extension[3].extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[3].extension[2].extension[0].valueCodeableConcept.coding[0].code | #1-month-in-retail |
| extension[3].extension[2].extension[0].valueCodeableConcept.coding[0].display | "1 month in network retail" |
| extension[3].extension[2].extension[1].url | "copayAmount" |
| extension[3].extension[2].extension[1].valueMoney.value | 70 |
| extension[3].extension[2].extension[2].url | "copayOption" |
| extension[3].extension[2].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[3].extension[2].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[3].extension[2].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[3].extension[2].extension[3].url | "coinsuranceRate" |
| extension[3].extension[2].extension[3].valueDecimal | "0" |
| extension[3].extension[2].extension[4].url | "coinsuranceOption" |
| extension[3].extension[2].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[3].extension[2].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[3].extension[2].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[3].extension[3].url | "costSharing" |
| extension[3].extension[3].extension[0].url | "pharmacyType" |
| extension[3].extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[3].extension[3].extension[0].valueCodeableConcept.coding[0].code | #1-month-out-retail |
| extension[3].extension[3].extension[0].valueCodeableConcept.coding[0].display | "1 month out of network retail" |
| extension[3].extension[3].extension[1].url | "copayAmount" |
| extension[3].extension[3].extension[1].valueMoney.value | 70 |
| extension[3].extension[3].extension[2].url | "copayOption" |
| extension[3].extension[3].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[3].extension[3].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[3].extension[3].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[3].extension[3].extension[3].url | "coinsuranceRate" |
| extension[3].extension[3].extension[3].valueDecimal | "0" |
| extension[3].extension[3].extension[4].url | "coinsuranceOption" |
| extension[3].extension[3].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[3].extension[3].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[3].extension[3].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[3].extension[4].url | "costSharing" |
| extension[3].extension[4].extension[0].url | "pharmacyType" |
| extension[3].extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[3].extension[4].extension[0].valueCodeableConcept.coding[0].code | #3-month-in-retail |
| extension[3].extension[4].extension[0].valueCodeableConcept.coding[0].display | "3 month in network retail" |
| extension[3].extension[4].extension[1].url | "copayAmount" |
| extension[3].extension[4].extension[1].valueMoney.value | 140 |
| extension[3].extension[4].extension[2].url | "copayOption" |
| extension[3].extension[4].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[3].extension[4].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[3].extension[4].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[3].extension[4].extension[3].url | "coinsuranceRate" |
| extension[3].extension[4].extension[3].valueDecimal | "0" |
| extension[3].extension[4].extension[4].url | "coinsuranceOption" |
| extension[3].extension[4].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[3].extension[4].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[3].extension[4].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[3].extension[5].url | "costSharing" |
| extension[3].extension[5].extension[0].url | "pharmacyType" |
| extension[3].extension[5].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[3].extension[5].extension[0].valueCodeableConcept.coding[0].code | #3-month-out-retail |
| extension[3].extension[5].extension[0].valueCodeableConcept.coding[0].display | "3 month out of network retail" |
| extension[3].extension[5].extension[1].url | "copayAmount" |
| extension[3].extension[5].extension[1].valueMoney.value | 140 |
| extension[3].extension[5].extension[2].url | "copayOption" |
| extension[3].extension[5].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[3].extension[5].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[3].extension[5].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[3].extension[5].extension[3].url | "coinsuranceRate" |
| extension[3].extension[5].extension[3].valueDecimal | "0" |
| extension[3].extension[5].extension[4].url | "coinsuranceOption" |
| extension[3].extension[5].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[3].extension[5].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[3].extension[5].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[4].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" |
| extension[4].extension[0].url | "drugTierID" |
| extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" |
| extension[4].extension[0].valueCodeableConcept.coding[0].code | #specialty |
| extension[4].extension[0].valueCodeableConcept.coding[0].display | "Specialty" |
| extension[4].extension[1].url | "mailOrder" |
| extension[4].extension[1].valueBoolean | "true" |
| extension[4].extension[2].url | "costSharing" |
| extension[4].extension[2].extension[0].url | "pharmacyType" |
| extension[4].extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[4].extension[2].extension[0].valueCodeableConcept.coding[0].code | #1-month-in-retail |
| extension[4].extension[2].extension[0].valueCodeableConcept.coding[0].display | "1 month in network retail" |
| extension[4].extension[2].extension[1].url | "copayAmount" |
| extension[4].extension[2].extension[1].valueMoney.value | 100 |
| extension[4].extension[2].extension[2].url | "copayOption" |
| extension[4].extension[2].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[4].extension[2].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[4].extension[2].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[4].extension[2].extension[3].url | "coinsuranceRate" |
| extension[4].extension[2].extension[3].valueDecimal | "0" |
| extension[4].extension[2].extension[4].url | "coinsuranceOption" |
| extension[4].extension[2].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[4].extension[2].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[4].extension[2].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[4].extension[3].url | "costSharing" |
| extension[4].extension[3].extension[0].url | "pharmacyType" |
| extension[4].extension[3].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[4].extension[3].extension[0].valueCodeableConcept.coding[0].code | #1-month-out-retail |
| extension[4].extension[3].extension[0].valueCodeableConcept.coding[0].display | "1 month out of network retail" |
| extension[4].extension[3].extension[1].url | "copayAmount" |
| extension[4].extension[3].extension[1].valueMoney.value | 100 |
| extension[4].extension[3].extension[2].url | "copayOption" |
| extension[4].extension[3].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[4].extension[3].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[4].extension[3].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[4].extension[3].extension[3].url | "coinsuranceRate" |
| extension[4].extension[3].extension[3].valueDecimal | "0" |
| extension[4].extension[3].extension[4].url | "coinsuranceOption" |
| extension[4].extension[3].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[4].extension[3].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[4].extension[3].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[4].extension[4].url | "costSharing" |
| extension[4].extension[4].extension[0].url | "pharmacyType" |
| extension[4].extension[4].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[4].extension[4].extension[0].valueCodeableConcept.coding[0].code | #3-month-in-retail |
| extension[4].extension[4].extension[0].valueCodeableConcept.coding[0].display | "3 month in network retail" |
| extension[4].extension[4].extension[1].url | "copayAmount" |
| extension[4].extension[4].extension[1].valueMoney.value | 200 |
| extension[4].extension[4].extension[2].url | "copayOption" |
| extension[4].extension[4].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[4].extension[4].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[4].extension[4].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[4].extension[4].extension[3].url | "coinsuranceRate" |
| extension[4].extension[4].extension[3].valueDecimal | "0" |
| extension[4].extension[4].extension[4].url | "coinsuranceOption" |
| extension[4].extension[4].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[4].extension[4].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[4].extension[4].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[4].extension[5].url | "costSharing" |
| extension[4].extension[5].extension[0].url | "pharmacyType" |
| extension[4].extension[5].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" |
| extension[4].extension[5].extension[0].valueCodeableConcept.coding[0].code | #3-month-out-retail |
| extension[4].extension[5].extension[0].valueCodeableConcept.coding[0].display | "3 month out of network retail" |
| extension[4].extension[5].extension[1].url | "copayAmount" |
| extension[4].extension[5].extension[1].valueMoney.value | 200 |
| extension[4].extension[5].extension[2].url | "copayOption" |
| extension[4].extension[5].extension[2].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" |
| extension[4].extension[5].extension[2].valueCodeableConcept.coding[0].code | #no-charge |
| extension[4].extension[5].extension[2].valueCodeableConcept.coding[0].display | "No Charge" |
| extension[4].extension[5].extension[3].url | "coinsuranceRate" |
| extension[4].extension[5].extension[3].valueDecimal | "0" |
| extension[4].extension[5].extension[4].url | "coinsuranceOption" |
| extension[4].extension[5].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" |
| extension[4].extension[5].extension[4].valueCodeableConcept.coding[0].code | #after-deductible |
| extension[4].extension[5].extension[4].valueCodeableConcept.coding[0].display | "After Deductible" |
| extension[5].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension" |
| extension[5].valueString | "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+" |
| extension[6].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension" |
| extension[6].valueString | "http://url/to/formulary/information" |
| extension[7].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension" |
| extension[7].valueString | "http://url/to/formulary/information" |
| extension[8].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension" |
| extension[8].valueString | "Patrick.Breen@carefirst.com" |
| extension[9].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension" |
| extension[9].valueString | "PREFERRED" |
| extension[10].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension" |
| extension[10].valueString | "HIOS-PLAN-ID" |
| status | "current" |
| mode | "snapshot" |
| title | "BluePreferred PPO HSA Silver $3,000" |
| date | "2015-06-12" |
| entry[0].item.reference | "MedicationKnowledge/cmsip9" |
IG © 2021+ HL7 Pharmacy Working Group. Package hl7.fhir.us.davinci-drug-formulary#1.1.0 based on FHIR 4.0.1. Generated 2021-10-15
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