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 |
{
"resourceType" : "InsurancePlan",
"id" : "PayerInsurancePlanA3002",
"meta" : {
"lastUpdated" : "2021-05-22T18:36:03.000+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: InsurancePlan</b><a name=\"PayerInsurancePlanA3002\"> </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 "PayerInsurancePlanA3002" Updated "2021-05-22 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:\u00a0A3002</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 A3002</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)555-3002\">+1 (888) 555-3002</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-FormularyD3002.html\">InsurancePlan/FormularyD3002</a> "Sample Medicare Advantage Part D Formulary D3002"</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>: Before 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>#before-deductible)</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>: 1 %<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>: 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>: 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>: 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>: 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>: 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>: After Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE.html\">Codes qualifying the type of cost share amount</a>#after-deductible)</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>"
},
"identifier" : [
{
"value" : "A3002"
}
],
"status" : "active",
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS",
"code" : "mediadv"
}
]
}
],
"name" : "Sample Medicare Advantage Plan A3002",
"period" : {
"start" : "2021-01-01",
"end" : "2021-12-31"
},
"coverageArea" : [
{
🔗 "reference" : "Location/UnitedStatesLocation"
}
],
"contact" : [
{
"purpose" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code" : "PATINF"
}
]
},
"telecom" : [
{
"system" : "phone",
"value" : "+1 (888) 555-3002"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "MARKETING"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Plan Marketing Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "SUMMARY"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Drug Plan Benefit Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "FORMULARY"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Drug Plan Formulary Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
}
],
"coverage" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
"valueReference" : {
🔗 "reference" : "InsurancePlan/FormularyD3002"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "DRUGPOL"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
"code" : "drug",
"display" : "Drug"
}
]
}
}
]
}
],
"plan" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
"code" : "drug",
"display" : "Drug"
}
]
},
"specificCost" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "1-month-in-retail",
"display" : "1 month in network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "before-deductible",
"display" : "Before Deductible"
}
]
}
],
"value" : {
"value" : 10,
"unit" : "$",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "coinsurance",
"display" : "Coinsurance"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
],
"value" : {
"value" : 1,
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
]
}
]
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "1-month-out-retail",
"display" : "1 month out of network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
],
"value" : {
"value" : 0,
"unit" : "$",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "coinsurance",
"display" : "Coinsurance"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
],
"value" : {
"value" : 0,
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
]
}
]
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "3-month-in-retail",
"display" : "3 month in network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
],
"value" : {
"value" : 0,
"unit" : "$",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "coinsurance",
"display" : "Coinsurance"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
],
"value" : {
"value" : 0,
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
]
}
]
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "3-month-out-retail",
"display" : "3 month out of network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
],
"value" : {
"value" : 0,
"unit" : "$",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "coinsurance",
"display" : "Coinsurance"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
],
"value" : {
"value" : 0,
"system" : "http://unitsofmeasure.org",
"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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