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: PayerInsurancePlanA3004t - JSON Representation

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{
  "resourceType" : "InsurancePlan",
  "id" : "PayerInsurancePlanA3004t",
  "meta" : {
    "lastUpdated" : "2021-08-04T18:36:03.000+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: InsurancePlan</b><a name=\"PayerInsurancePlanA3004t\"> </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 InsurancePlan &quot;PayerInsurancePlanA3004t&quot; Updated &quot;2021-08-04 18:36:03+0000&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-PayerInsurancePlan.html\">Payer Insurance Plan</a></p></div><p><b>identifier</b>: id:\u00a0A3004t</p><p><b>status</b>: active</p><p><b>type</b>: Medicare Advantage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1.1/CodeSystem-InsuranceProductTypeCS.html\">Insurance Product Type</a>#mediadv)</span></p><p><b>name</b>: Sample Medicare Advantage Plan A3004t</p><p><b>period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>coverageArea</b>: <a href=\"Location-UnitedStatesLocation.html\">Location/UnitedStatesLocation</a> &quot;United States Area&quot;</p><blockquote><p><b>contact</b></p><p><b>purpose</b>: Patient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-contactentity-type.html\">Contact entity type</a>#PATINF)</span></p><p><b>telecom</b>: <a href=\"tel:+1(888)555-3004\">+1 (888) 555-3004</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Marketing Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for type of plan contact</a>#MARKETING)</span></p><p><b>name</b>: Sample Medicare Advantage Plan Marketing Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Summary Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for type of plan contact</a>#SUMMARY)</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Benefit Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: Plan Formulary Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for type of plan contact</a>#FORMULARY)</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Formulary Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>coverage</b></p><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>type</b>: drug policy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ActCode.html\">ActCode</a>#DRUGPOL)</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>Drug <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-insurance-plan-type.html\">Insurance plan type</a>#drug)</span></td></tr></table></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: Drug <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-insurance-plan-type.html\">Insurance plan type</a>#drug)</span></p><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in 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>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <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>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 10 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 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>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <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>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 10 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in 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-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <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>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 20 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</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><blockquote><p><b>benefit</b></p><p><b>type</b>: Generic <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>#generic)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 20 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in 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>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <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>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 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>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <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>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in 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-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <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>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</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><blockquote><p><b>benefit</b></p><p><b>type</b>: Zero cost-share preventative <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>#zero-cost-share-preventative)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in 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>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</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><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 50 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 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>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</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><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 50 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in 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-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</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><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</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><blockquote><p><b>benefit</b></p><p><b>type</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><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in 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>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-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>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 70 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 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>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-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>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 70 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in 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-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-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>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 140 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</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><blockquote><p><b>benefit</b></p><p><b>type</b>: Non-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>#non-preferred-brand)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 140 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 month in 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>#1-month-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <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>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 1 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>#1-month-out-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <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>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: 3 month in 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-in-retail)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <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>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 200 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</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><blockquote><p><b>benefit</b></p><p><b>type</b>: Specialty <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>#specialty)</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: Copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#copay)</span></p><p><b>qualifiers</b>: No Charge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#no-charge)</span></p><p><b>value</b>: 200 $<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'USD')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for benefit type of cost</a>#coinsurance)</span></p><p><b>qualifiers</b>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>"
  },
  "identifier" : [
    {
      "value" : "A3004t"
    }
  ],
  "status" : "active",
  "type" : [
    {
      "coding" : [
        {
          "system" : "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS",
          "code" : "mediadv"
        }
      ]
    }
  ],
  "name" : "Sample Medicare Advantage Plan A3004t",
  "period" : {
    "start" : "2021-01-01",
    "end" : "2021-12-31"
  },
  "coverageArea" : [
    {
      🔗 "reference" : "Location/UnitedStatesLocation"
    }
  ],
  "contact" : [
    {
      "purpose" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/contactentity-type",
            "code" : "PATINF"
          }
        ]
      },
      "telecom" : [
        {
          "system" : "phone",
          "value" : "+1 (888) 555-3004"
        }
      ]
    },
    {
      "purpose" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
            "code" : "MARKETING"
          }
        ]
      },
      "name" : {
        "text" : "Sample Medicare Advantage Plan Marketing Website"
      },
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://url/to/health/plan/information"
        }
      ]
    },
    {
      "purpose" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
            "code" : "SUMMARY"
          }
        ]
      },
      "name" : {
        "text" : "Sample Medicare Advantage Drug Plan Benefit Website"
      },
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://url/to/health/plan/information"
        }
      ]
    },
    {
      "purpose" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
            "code" : "FORMULARY"
          }
        ]
      },
      "name" : {
        "text" : "Sample Medicare Advantage Drug Plan Formulary Website"
      },
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://url/to/health/plan/information"
        }
      ]
    }
  ],
  "coverage" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
          "valueReference" : {
            🔗 "reference" : "InsurancePlan/FormularyD3004t"
          }
        }
      ],
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "DRUGPOL"
          }
        ]
      },
      "benefit" : [
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
                "code" : "drug",
                "display" : "Drug"
              }
            ]
          }
        }
      ]
    }
  ],
  "plan" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
            "code" : "drug",
            "display" : "Drug"
          }
        ]
      },
      "specificCost" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "1-month-in-retail",
                "display" : "1 month in network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "generic",
                    "display" : "Generic"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 10,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "after-deductible",
                          "display" : "After Deductible"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "1-month-out-retail",
                "display" : "1 month out of network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "generic",
                    "display" : "Generic"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 10,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "after-deductible",
                          "display" : "After Deductible"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "3-month-in-retail",
                "display" : "3 month in network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "generic",
                    "display" : "Generic"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 20,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "after-deductible",
                          "display" : "After Deductible"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "3-month-out-retail",
                "display" : "3 month out of network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "generic",
                    "display" : "Generic"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 20,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "after-deductible",
                          "display" : "After Deductible"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "1-month-in-retail",
                "display" : "1 month in network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "zero-cost-share-preventative",
                    "display" : "Zero cost-share preventative"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "1-month-out-retail",
                "display" : "1 month out of network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "zero-cost-share-preventative",
                    "display" : "Zero cost-share preventative"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "3-month-in-retail",
                "display" : "3 month in network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
                    "code" : "zero-cost-share-preventative",
                    "display" : "Zero cost-share preventative"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "unit" : "$",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                },
                {
                  "type" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "coding" : [
                        {
                          "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
                          "code" : "no-charge",
                          "display" : "No Charge"
                        }
                      ]
                    }
                  ],
                  "value" : {
                    "value" : 0,
                    "system" : "http://unitsofmeasure.org",
                    "code" : "%"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
                "code" : "3-month-out-retail",
                "display" : "3 month out of network retail"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
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