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
Example: CoveragePlanV3004t

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:List;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "CoveragePlanV3004t"];
  fhir:Resource.meta [
     fhir:Meta.versionId [ fhir:value "1" ];
     fhir:Meta.lastUpdated [ fhir:value "2019-05-22T18:36:03.000+00:00"^^xsd:dateTime ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan>     ]
  ];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.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>"
  ];
  fhir:DomainResource.extension [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "drugTierID" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "generic" ];
           fhir:Coding.display [ fhir:value "Generic" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "mailOrder" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-in-retail" ];
             fhir:Coding.display [ fhir:value "1 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "10"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-out-retail" ];
             fhir:Coding.display [ fhir:value "1 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "10"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-in-retail" ];
             fhir:Coding.display [ fhir:value "3 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "20"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-out-retail" ];
             fhir:Coding.display [ fhir:value "3 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "20"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 1;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "drugTierID" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "zero-cost-share-preventive" ];
           fhir:Coding.display [ fhir:value "Zero cost-share preventive" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "mailOrder" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-in-retail" ];
             fhir:Coding.display [ fhir:value "1 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-out-retail" ];
             fhir:Coding.display [ fhir:value "1 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-in-retail" ];
             fhir:Coding.display [ fhir:value "3 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-out-retail" ];
             fhir:Coding.display [ fhir:value "3 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "0"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 2;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "drugTierID" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "preferred-brand" ];
           fhir:Coding.display [ fhir:value "Preferred Brand" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "mailOrder" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-in-retail" ];
             fhir:Coding.display [ fhir:value "1 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "50"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-out-retail" ];
             fhir:Coding.display [ fhir:value "1 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "50"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-in-retail" ];
             fhir:Coding.display [ fhir:value "3 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-out-retail" ];
             fhir:Coding.display [ fhir:value "3 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 3;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "drugTierID" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "non-preferred-brand" ];
           fhir:Coding.display [ fhir:value "Non-Preferred Brand" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "mailOrder" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-in-retail" ];
             fhir:Coding.display [ fhir:value "1 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "70"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-out-retail" ];
             fhir:Coding.display [ fhir:value "1 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "70"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-in-retail" ];
             fhir:Coding.display [ fhir:value "3 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "140"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-out-retail" ];
             fhir:Coding.display [ fhir:value "3 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "140"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 4;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "drugTierID" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS" ];
           fhir:Coding.code [ fhir:value "specialty" ];
           fhir:Coding.display [ fhir:value "Specialty" ]         ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "mailOrder" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 2;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-in-retail" ];
             fhir:Coding.display [ fhir:value "1 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 3;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "1-month-out-retail" ];
             fhir:Coding.display [ fhir:value "1 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "100"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 4;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-in-retail" ];
             fhir:Coding.display [ fhir:value "3 month in network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "200"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ], [
       fhir:index 5;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "pharmacyType" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS" ];
             fhir:Coding.code [ fhir:value "3-month-out-retail" ];
             fhir:Coding.display [ fhir:value "3 month out of network retail" ]           ]         ]       ], [
         fhir:index 1;
         fhir:Extension.url [ fhir:value "copayAmount" ];
         fhir:Extension.valueMoney [
           fhir:Money.value [ fhir:value "200"^^xsd:decimal ]         ]       ], [
         fhir:index 2;
         fhir:Extension.url [ fhir:value "copayOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS" ];
             fhir:Coding.code [ fhir:value "no-charge" ];
             fhir:Coding.display [ fhir:value "No Charge" ]           ]         ]       ], [
         fhir:index 3;
         fhir:Extension.url [ fhir:value "coinsuranceRate" ];
         fhir:Extension.valueDecimal [ fhir:value "0"^^xsd:decimal ]       ], [
         fhir:index 4;
         fhir:Extension.url [ fhir:value "coinsuranceOption" ];
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS" ];
             fhir:Coding.code [ fhir:value "after-deductible" ];
             fhir:Coding.display [ fhir:value "After Deductible" ]           ]         ]       ];
       fhir:Extension.url [ fhir:value "costSharing" ]     ];
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension" ]
  ], [
     fhir:index 5;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension" ];
     fhir:Extension.valueString [ fhir:value "https://content.carefirst.com/sbc/D,$0/ D,$0/ D,$0/ D,$0/ D,$0B+" ]
  ], [
     fhir:index 6;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension" ];
     fhir:Extension.valueString [ fhir:value "http://url/to/formulary/information" ]
  ], [
     fhir:index 7;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension" ];
     fhir:Extension.valueString [ fhir:value "http://url/to/formulary/information" ]
  ], [
     fhir:index 8;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension" ];
     fhir:Extension.valueString [ fhir:value "Patrick.Breen@carefirst.com" ]
  ], [
     fhir:index 9;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension" ];
     fhir:Extension.valueString [ fhir:value "PREFERRED" ]
  ], [
     fhir:index 10;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension" ];
     fhir:Extension.valueString [ fhir:value "HIOS-PLAN-ID" ]
  ];
  fhir:List.identifier [
     fhir:index 0;
     fhir:Identifier.value [ fhir:value "40308VA0240008" ]
  ];
  fhir:List.status [ fhir:value "current"];
  fhir:List.mode [ fhir:value "snapshot"];
  fhir:List.title [ fhir:value "BluePreferred PPO HSA Silver $3,000"];
  fhir:List.date [ fhir:value "2015-06-12"^^xsd:date];
  fhir:List.entry [
     fhir:index 0;
     fhir:List.entry.item [
       fhir:Reference.reference [ fhir:value "MedicationKnowledge/cmsip9" ]     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.