DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.1 - STU 2
DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.1 - STU 2
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
| Page standards status: Informative |
@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:InsurancePlan ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "PayerInsurancePlanA3004t"] ; # fhir:meta [ fhir:lastUpdated [ fhir:v "2021-08-04T18:36:03.000+00:00"^^xsd:dateTime ] ; ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir: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 "PayerInsurancePlanA3004t" Updated "2021-08-04 18:36:03+0000" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-PayerInsurancePlan.html\">Payer Insurance Plan</a></p></div><p><b>identifier</b>: id: A3004t</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 --> 2021-12-31</p><p><b>coverageArea</b>: <a href=\"Location-UnitedStatesLocation.html\">Location/UnitedStatesLocation</a> "United States Area"</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> "Sample Medicare Advantage Part D Formulary D3004t"</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>" ] ; # fhir:identifier ( [ fhir:value [ fhir:v "A3004t" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type ( [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "mediadv" ] ] ) ] ) ; # fhir:name [ fhir:v "Sample Medicare Advantage Plan A3004t"] ; # fhir:period [ fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ; fhir:end [ fhir:v "2021-12-31"^^xsd:date ] ] ; # fhir:coverageArea ( [ fhir:reference [ fhir:v "Location/UnitedStatesLocation" ] ] ) ; # fhir:contact ( [ fhir:purpose [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/contactentity-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "PATINF" ] ] ) ] ; ( fhir:telecom [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "+1 (888) 555-3004" ] ] ) ] [ fhir:purpose [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "MARKETING" ] ] ) ] ; fhir:name [ fhir:text [ fhir:v "Sample Medicare Advantage Plan Marketing Website" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "http://url/to/health/plan/information" ] ] ) ] [ fhir:purpose [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "SUMMARY" ] ] ) ] ; fhir:name [ fhir:text [ fhir:v "Sample Medicare Advantage Drug Plan Benefit Website" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "http://url/to/health/plan/information" ] ] ) ] [ fhir:purpose [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "FORMULARY" ] ] ) ] ; fhir:name [ fhir:text [ fhir:v "Sample Medicare Advantage Drug Plan Formulary Website" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "http://url/to/health/plan/information" ] ] ) ] ) ; # fhir:coverage ( [ ( 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:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ; fhir:code [ fhir:v "DRUGPOL" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/insurance-plan-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "drug" ] ; fhir:display [ fhir:v "Drug" ] ] ) ] ] ) ] ) ; # fhir:plan ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/insurance-plan-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "drug" ] ; fhir:display [ fhir:v "Drug" ] ] ) ] ; ( fhir:specificCost [ fhir:category [ ( 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 "1-month-in-retail" ] ; fhir:display [ fhir:v "1 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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 "generic" ] ; fhir:display [ fhir:v "Generic" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "10"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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 "1-month-out-retail" ] ; fhir:display [ fhir:v "1 month out of network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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 "generic" ] ; fhir:display [ fhir:v "Generic" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "10"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "3-month-in-retail" ] ; fhir:display [ fhir:v "3 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "generic" ] ; fhir:display [ fhir:v "Generic" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "20"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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:benefit [ fhir:type [ ( 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 "generic" ] ; fhir:display [ fhir:v "Generic" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "20"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "1-month-in-retail" ] ; fhir:display [ fhir:v "1 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "zero-cost-share-preventative" ] ; fhir:display [ fhir:v "Zero cost-share preventative" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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 "1-month-out-retail" ] ; fhir:display [ fhir:v "1 month out of network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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 "zero-cost-share-preventative" ] ; fhir:display [ fhir:v "Zero cost-share preventative" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "3-month-in-retail" ] ; fhir:display [ fhir:v "3 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "zero-cost-share-preventative" ] ; fhir:display [ fhir:v "Zero cost-share preventative" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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:benefit [ fhir:type [ ( 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 "zero-cost-share-preventative" ] ; fhir:display [ fhir:v "Zero cost-share preventative" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "1-month-in-retail" ] ; fhir:display [ fhir:v "1 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "preferred-brand" ] ; fhir:display [ fhir:v "Preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "50"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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 "1-month-out-retail" ] ; fhir:display [ fhir:v "1 month out of network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "50"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "3-month-in-retail" ] ; fhir:display [ fhir:v "3 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "preferred-brand" ] ; fhir:display [ fhir:v "Preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "100"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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:benefit [ fhir:type [ ( 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:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "100"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "1-month-in-retail" ] ; fhir:display [ fhir:v "1 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "non-preferred-brand" ] ; fhir:display [ fhir:v "Non-preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "70"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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 "1-month-out-retail" ] ; fhir:display [ fhir:v "1 month out of network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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 "non-preferred-brand" ] ; fhir:display [ fhir:v "Non-preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "70"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "3-month-in-retail" ] ; fhir:display [ fhir:v "3 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "non-preferred-brand" ] ; fhir:display [ fhir:v "Non-preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "140"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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:benefit [ fhir:type [ ( 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 "non-preferred-brand" ] ; fhir:display [ fhir:v "Non-preferred Brand" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "140"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "1-month-in-retail" ] ; fhir:display [ fhir:v "1 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "specialty" ] ; fhir:display [ fhir:v "Specialty" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "100"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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 "1-month-out-retail" ] ; fhir:display [ fhir:v "1 month out of network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( 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 "specialty" ] ; fhir:display [ fhir:v "Specialty" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "100"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "3-month-in-retail" ] ; fhir:display [ fhir:v "3 month in network retail" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "specialty" ] ; fhir:display [ fhir:v "Specialty" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] [ fhir:category [ ( 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:benefit [ fhir:type [ ( 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 "specialty" ] ; fhir:display [ fhir:v "Specialty" ] ] ) ] ; ( fhir:cost [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "no-charge" ] ; fhir:display [ fhir:v "No Charge" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:unit [ fhir:v "$" ] ; fhir:system [ fhir:v "urn:iso:std:iso:4217"^^xsd:anyURI ] ; fhir:code [ fhir:v "USD" ] ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Coinsurance" ] ] ) ] ; ( fhir:qualifiers [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ; fhir:code [ fhir:v "after-deductible" ] ; fhir:display [ fhir:v "After Deductible" ] ] ) ] ) ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "%" ] ] ] ) ] ) ] ) ] ) . #
IG © 2022+ HL7 International / Pharmacy. Package hl7.fhir.us.davinci-drug-formulary#2.0.1 based on FHIR 4.0.1. Generated 2023-12-01
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change