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 
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"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
"code" : "1-month-in-retail",
"display" : "1 month in network retail"
}
]
}
},
{
"url" : "copayAmount",
"valueMoney" : {
"value" : 100
}
},
{
"url" : "copayOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
},
{
"url" : "coinsuranceRate",
"valueDecimal" : 0
},
{
"url" : "coinsuranceOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
}
],
"url" : "costSharing"
},
{
"extension" : [
{
"url" : "pharmacyType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
"code" : "1-month-out-retail",
"display" : "1 month out of network retail"
}
]
}
},
{
"url" : "copayAmount",
"valueMoney" : {
"value" : 100
}
},
{
"url" : "copayOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
},
{
"url" : "coinsuranceRate",
"valueDecimal" : 0
},
{
"url" : "coinsuranceOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
}
],
"url" : "costSharing"
},
{
"extension" : [
{
"url" : "pharmacyType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
"code" : "3-month-in-retail",
"display" : "3 month in network retail"
}
]
}
},
{
"url" : "copayAmount",
"valueMoney" : {
"value" : 200
}
},
{
"url" : "copayOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
},
{
"url" : "coinsuranceRate",
"valueDecimal" : 0
},
{
"url" : "coinsuranceOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
}
],
"url" : "costSharing"
},
{
"extension" : [
{
"url" : "pharmacyType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
"code" : "3-month-out-retail",
"display" : "3 month out of network retail"
}
]
}
},
{
"url" : "copayAmount",
"valueMoney" : {
"value" : 200
}
},
{
"url" : "copayOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
},
{
"url" : "coinsuranceRate",
"valueDecimal" : 0
},
{
"url" : "coinsuranceOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
"code" : "after-deductible",
"display" : "After 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",
"valueUrl" : "https://content.carefirst.com/sbc/D,$0/%20D,$0/%20D,$0/%20D,$0/%20D,$0B+"
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension",
"valueUrl" : "http://url/to/formulary/information"
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
"valueUrl" : "http://url/to/formulary/information"
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension",
"valueUrl" : "mailto:Patrick.Breen@carefirst.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" : "40308VA0240008"
}
],
"status" : "current",
"mode" : "snapshot",
"title" : "BluePreferred PPO HSA Silver $3,000",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "DRUGPOL",
"display" : "drug policy"
}
]
},
"date" : "2015-06-12"
}
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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