DaVinci Payer Data Exchange (PDex) US Drug Formulary STU 1

This page is part of the US Drug Formulary (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

Example: CoveragePlanV3002

{
  "resourceType" : "List",
  "id" : "CoveragePlanV3002",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2019-05-22T18:36:03.000+00:00",
    "profile" : [
      "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: CoveragePlanV3002</p><p><b>meta</b>: </p><p><b>identifier</b>: test1</p><p><b>status</b>: current</p><p><b>mode</b>: snapshot</p><p><b>title</b>: Sample Gold Health Plan</p><p><b>date</b>: Jun 12, 2015 12:00:00 AM</p><h3>Entries</h3><table class=\"grid\"><tr><td>-</td><td><b>Item</b></td></tr><tr><td>*</td><td><a href=\"MedicationKnowledge-FormularyDrugV3001.html\">Generated Summary: id: FormularyDrugV3001; <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>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "drugTierID",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
                "code" : "generic",
                "display" : "Generic"
              }
            ]
          }
        },
        {
          "url" : "mailOrder",
          "valueBoolean" : true
        },
        {
          "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" : 10
              }
            },
            {
              "url" : "copayOption",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                    "code" : "before-deductible",
                    "display" : "Before Deductible"
                  }
                ]
              }
            },
            {
              "url" : "coinsuranceRate",
              "valueDecimal" : 1
            },
            {
              "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" : 0
              }
            },
            {
              "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" : 0
              }
            },
            {
              "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" : 0
              }
            },
            {
              "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",
      "valueString" : "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension",
      "valueString" : "http://url/to/formulary/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
      "valueString" : "http://url/to/formulary/information"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension",
      "valueString" : "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" : "test1"
    }
  ],
  "status" : "current",
  "mode" : "snapshot",
  "title" : "Sample Gold Health Plan",
  "date" : "2015-06-12",
  "entry" : [
    {
      "item" : {
        "reference" : "MedicationKnowledge/FormularyDrugV3001"
      }
    }
  ]
}