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

Example InsurancePlan: PayerInsurancePlanA1002

Page standards status: Informative

Generated Narrative: InsurancePlan

Resource InsurancePlan "PayerInsurancePlanA1002" Updated "2021-08-22 18:36:03+0000"

Profile: Payer Insurance Plan

identifier: id: A1002

status: active

type: Medicare Advantage (Insurance Product Type#mediadv)

name: Sample Medicare Advantage Plan A1002

period: 2021-01-01 --> 2021-12-31

coverageArea: Location/StateOfCTLocation "State of CT Area"

contact

purpose: Patient (Contact entity type#PATINF)

telecom: +1 (888) 555-1002

contact

purpose: Plan Marketing Information (Codes for type of plan contact#MARKETING)

name: Sample Medicare Advantage Plan Marketing Website

telecom: http://url/to/health/plan/information

contact

purpose: Plan Summary Information (Codes for type of plan contact#SUMMARY)

name: Sample Medicare Advantage Drug Plan Benefit Website

telecom: http://url/to/health/plan/information

contact

purpose: Plan Formulary Information (Codes for type of plan contact#FORMULARY)

name: Sample Medicare Advantage Drug Plan Formulary Website

telecom: http://url/to/health/plan/information

coverage

Formulary Reference: InsurancePlan/FormularyD1002 "Sample Medicare Advantage Part D Formulary D1002"

type: drug policy (ActCode#DRUGPOL)

Benefits

-Type
*Drug (Insurance plan type#drug)

plan

type: Drug (Insurance plan type#drug)

specificCost

category: 1 month in network retail (Codes for pharmacy benefit types#1-month-in-retail)

benefit

type: Brand (Codes for medication drug tiers in health plans#brand)

cost

type: Copay (Codes for benefit type of cost#copay)

qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)

value: 20 $ (Details: urn:iso:std:iso:4217 code USD = 'USD')

cost

type: Coinsurance (Codes for benefit type of cost#coinsurance)

qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)

value: 20 % (Details: UCUM code % = '%')