DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.1 - STU 2 United States of America flag

This page is part of the US Drug Formulary (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: FormularyItem-D3004t-1049640 - TTL Representation

Page standards status: Informative

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@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:Basic ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "FormularyItem-D3004t-1049640"] ; # 
  fhir:meta [
fhir:lastUpdated [ fhir:v "2021-08-22T18:36:03.000+00:00"^^xsd:dateTime ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Basic</b><a name=\"FormularyItem-D3004t-1049640\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Basic &quot;FormularyItem-D3004t-1049640&quot; Updated &quot;2021-08-22 18:36:03+0000&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-FormularyItem.html\">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD3004t.html\">InsurancePlan/FormularyD3004t</a> &quot;Sample Medicare Advantage Part D Formulary D3004t&quot;</p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</b>: 3 month out of network retail <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for pharmacy benefit types</a>#3-month-out-retail)</span></p><p><b>Drug Tier ID</b>: Preferred Brand <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-DrugTierCS-TEMPORARY-TRIAL-USE.html\">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><p><b>Availability Period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><p><b>code</b>: Formulary Item <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-InsuranceItemTypeCS.html\">Codes for insurance item type</a>#formulary-item)</span></p><p><b>subject</b>: <a href=\"MedicationKnowledge-FormularyDrug-1049640.html\">MedicationKnowledge/FormularyDrug-1049640</a></p></div>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "InsurancePlan/FormularyD3004t" ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityStatus-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "active" ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyBenefitType-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "3-month-out-retail" ] ;
fhir:display [ fhir:v "3 month out of network retail" ]       ] )     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "preferred-brand" ] ;
fhir:display [ fhir:v "Preferred Brand" ]       ] )     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityPeriod-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Period ;
fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-12-31"^^xsd:date ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorization-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorizationNewStartsOnly-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimit-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimitNewStartsOnly-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimit-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] ) ; # 
  fhir:code [
    ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "formulary-item" ] ;
fhir:display [ fhir:v "Formulary Item" ]     ] )
  ] ; # 
  fhir:subject [
fhir:reference [ fhir:v "MedicationKnowledge/FormularyDrug-1049640" ]
  ] . #