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. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
Generated Narrative: InsurancePlan
Resource InsurancePlan "PayerInsurancePlanA3002" Updated "2021-05-22 18:36:03+0000"
Profile: Payer Insurance Plan
identifier: id: A3002
status: active
type: Medicare Advantage (Insurance Product Type#mediadv)
name: Sample Medicare Advantage Plan A3002
period: 2021-01-01 --> 2021-12-31
coverageArea: Location/UnitedStatesLocation "United States Area"
contact
purpose: Patient (Contact entity type#PATINF)
telecom: +1 (888) 555-3002
contact
purpose: Plan Marketing Information (Codes for type of plan contact#MARKETING)
name: Sample Medicare Advantage Plan Marketing Website
contact
purpose: Plan Summary Information (Codes for type of plan contact#SUMMARY)
name: Sample Medicare Advantage Drug Plan Benefit Website
contact
purpose: Plan Formulary Information (Codes for type of plan contact#FORMULARY)
name: Sample Medicare Advantage Drug Plan Formulary Website
coverage
Formulary Reference: InsurancePlan/FormularyD3002 "Sample Medicare Advantage Part D Formulary D3002"
type: drug policy (ActCode#DRUGPOL)
Benefits
Type Drug (Insurance plan type#drug)
plan
type: Drug (Insurance plan type#drug)
specificCost
category: 1 month in network retail (Codes for pharmacy benefit types#1-month-in-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: Before Deductible (Codes qualifying the type of cost share amount#before-deductible)
value: 10 $ (Details: urn:iso:std:iso:4217 code USD = 'USD')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)
value: 1 % (Details: UCUM code % = '%')
specificCost
category: 1 month out of network retail (Codes for pharmacy benefit types#1-month-out-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes qualifying the type of cost share amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'USD')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month in network retail (Codes for pharmacy benefit types#3-month-in-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes qualifying the type of cost share amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'USD')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)
value: 0 % (Details: UCUM code % = '%')
specificCost
category: 3 month out of network retail (Codes for pharmacy benefit types#3-month-out-retail)
benefit
type: Generic (Codes for medication drug tiers in health plans#generic)
cost
type: Copay (Codes for benefit type of cost#copay)
qualifiers: No Charge (Codes qualifying the type of cost share amount#no-charge)
value: 0 $ (Details: urn:iso:std:iso:4217 code USD = 'USD')
cost
type: Coinsurance (Codes for benefit type of cost#coinsurance)
qualifiers: After Deductible (Codes qualifying the type of cost share amount#after-deductible)
value: 0 % (Details: UCUM code % = '%')
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
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