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 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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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: CoveragePlanV3004t</p><p><b>meta</b>: </p><p><b>identifier</b>: 40308VA0240008</p><p><b>status</b>: current</p><p><b>mode</b>: snapshot</p><p><b>title</b>: BluePreferred PPO HSA Silver $3,000</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-cmsip9.html\">Generated Summary: id: cmsip9; <span title=\"Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 1000091}\">doxepin HCl 5 % Topical Cream</span></a></td></tr></table></div>"
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}
]
}
},
{
"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" : 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",
"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" : "40308VA0240008"
}
],
"status" : "current",
"mode" : "snapshot",
"title" : "BluePreferred PPO HSA Silver $3,000",
"date" : "2015-06-12",
"entry" : [
{
"item" : {
"reference" : "MedicationKnowledge/cmsip9"
}
}
]
}
©2020+
HL7 Pharmacy WG.
Package hl7.fhir.us.davinci-drug-formulary#1.0.0 based on FHIR 4.0.1.
Generated 2020-01-21.
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