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. For a full list of available versions, see the Directory of published versions
: FormularyItem-D1002-1049640 - JSON Representation
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{
"resourceType" : "Basic",
"id" : "FormularyItem-D1002-1049640",
"meta" : {
"lastUpdated" : "2021-08-22T18:36:03.000+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Basic</b><a name=\"FormularyItem-D1002-1049640\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Basic "FormularyItem-D1002-1049640" Updated "2021-08-22 18:36:03+0000" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-FormularyItem.html\">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD1002.html\">InsurancePlan/FormularyD1002</a> "Sample Medicare Advantage Part D Formulary D1002"</p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</b>: 3 month out of network retail <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for pharmacy benefit types</a>#3-month-out-retail)</span></p><p><b>Drug Tier ID</b>: 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>#brand)</span></p><p><b>Availability Period</b>: 2021-01-01 --> 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><blockquote><p><b>Quantity Limit Detail</b></p><blockquote><p><b>url</b></p><code>Rolling</code></blockquote><p><b>value</b>: Count 60 times, Once per 30 days</p><blockquote><p><b>url</b></p><code>MaximumDaily</code></blockquote><p><b>value</b>: 2</p><blockquote><p><b>url</b></p><code>DaysSupply</code></blockquote><p><b>value</b>: Count 1 times, Once per 180 days</p></blockquote><p><b>Additional Coverage Information</b>: Prior Authorization required only with a newly started medication\nStep Therapy required.</p><p><b>code</b>: Formulary Item <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-InsuranceItemTypeCS.html\">Codes for insurance item type</a>#formulary-item)</span></p><p><b>subject</b>: <a href=\"MedicationKnowledge-FormularyDrug-1049640.html\">MedicationKnowledge/FormularyDrug-1049640</a></p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
"valueReference" : {
🔗 "reference" : "InsurancePlan/FormularyD1002"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityStatus-extension",
"valueCode" : "active"
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyBenefitType-extension",
"valueCodeableConcept" : {
"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"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "brand",
"display" : "Brand"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityPeriod-extension",
"valuePeriod" : {
"start" : "2021-01-01",
"end" : "2021-12-31"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorization-extension",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorizationNewStartsOnly-extension",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimit-extension",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimitNewStartsOnly-extension",
"valueBoolean" : false
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimit-extension",
"valueBoolean" : true
},
{
"extension" : [
{
"url" : "Rolling",
"valueTiming" : {
"repeat" : {
"count" : 60,
"period" : 30,
"periodUnit" : "d"
}
}
},
{
"url" : "MaximumDaily",
"valueQuantity" : {
"value" : 2
}
},
{
"url" : "DaysSupply",
"valueTiming" : {
"repeat" : {
"boundsDuration" : {
"value" : 365,
"system" : "http://unitsofmeasure.org",
"code" : "d"
},
"count" : 1,
"period" : 180,
"periodUnit" : "d"
}
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimitDetail-extension"
},
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AdditionalCoverageInformation-extension",
"valueMarkdown" : "Prior Authorization required only with a newly started medication\nStep Therapy required."
}
],
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS",
"code" : "formulary-item",
"display" : "Formulary Item"
}
]
},
"subject" : {
🔗 "reference" : "MedicationKnowledge/FormularyDrug-1049640"
}
}
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