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

This page is part of the US Drug Formulary (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: FormularyItem-D1002-1049640 - XML Representation

Page standards status: Informative

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<Basic xmlns="http://hl7.org/fhir">
  <id value="FormularyItem-D1002-1049640"/>
  <meta>
    <lastUpdated value="2021-08-22T18:36:03.000+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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 &quot;FormularyItem-D1002-1049640&quot; Updated &quot;2021-08-22 18:36:03+0000&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-usdf-FormularyItem.html">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href="InsurancePlan-FormularyD1002.html">InsurancePlan/FormularyD1002</a> &quot;Sample Medicare Advantage Part D Formulary D1002&quot;</p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</b>: 3 month out of network retail <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE.html">Codes for pharmacy benefit types</a>#3-month-out-retail)</span></p><p><b>Drug Tier ID</b>: 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 --&gt; 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><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
Step 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>
  </text>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension">
    <valueReference>🔗 
      <reference value="InsurancePlan/FormularyD1002"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityStatus-extension">
    <valueCode value="active"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyBenefitType-extension">
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="3-month-out-retail"/>
        <display value="3 month out of network retail"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension">
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"/>
        <code value="brand"/>
        <display value="Brand"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityPeriod-extension">
    <valuePeriod>
      <start value="2021-01-01"/>
      <end value="2021-12-31"/>
    </valuePeriod>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorization-extension">
    <valueBoolean value="true"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorizationNewStartsOnly-extension">
    <valueBoolean value="true"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimit-extension">
    <valueBoolean value="true"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimitNewStartsOnly-extension">
    <valueBoolean value="false"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimit-extension">
    <valueBoolean value="true"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimitDetail-extension">
    <extension url="Rolling">
      <valueTiming>
        <repeat>
          <count value="60"/>
          <period value="30"/>
          <periodUnit value="d"/>
        </repeat>
      </valueTiming>
    </extension>
    <extension url="MaximumDaily">
      <valueQuantity>
        <value value="2"/>
      </valueQuantity>
    </extension>
    <extension url="DaysSupply">
      <valueTiming>
        <repeat>
          <boundsDuration>
            <value value="365"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="d"/>
          </boundsDuration>
          <count value="1"/>
          <period value="180"/>
          <periodUnit value="d"/>
        </repeat>
      </valueTiming>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AdditionalCoverageInformation-extension">
    <valueMarkdown
                   value="Prior Authorization required only with a newly started medication
Step Therapy required."/>
  </extension>
  <code>
    <coding>
      <system
              value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS"/>
      <code value="formulary-item"/>
      <display value="Formulary Item"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="MedicationKnowledge/FormularyDrug-1049640"/>
  </subject>
</Basic>