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


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