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 V1002 - JSON Representation

Raw json | Download


{
  "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: 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>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "drugTierID",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
                "code" : "brand",
                "display" : "Brand"
              }
            ]
          }
        },
        {
          "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"
                  }
                ]
              }
            },
            {
              "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"
                  }
                ]
              }
            },
            {
              "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" : "http://url/to/health/plan/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
      "valueUrl" : "http://url/to/health/plan/information"
    },
    {
      "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-EmailPlanContact-extension",
      "valueUrl" : "mailto: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",
  "code" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code" : "DRUGPOL",
        "display" : "drug policy"
      }
    ]
  },
  "date" : "2015-06-12"
}