DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.1.0 - STU 1.1

This page is part of the US Drug Formulary (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

Example List: Coverage Plan V1002

Sample Gold Health Plan

Date: 2015-06-12Mode: snapshotStatus: currentCode: drug policy
Items

Notes:

Field Value
resourceType "List"
meta.profile[0] "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
id "covplanV1002"
identifier[0].value HIOS-PLAN-ID
status "current"
mode "snapshot"
title "Sample Gold Health Plan"
date "2015-06-12"
entry[0].item.reference "MedicationKnowledge/formularydrugV1002"
extension[0].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
extension[0].extension[0].url "drugTierID"
extension[0].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"
extension[0].extension[0].valueCodeableConcept.coding[0].code #brand
extension[0].extension[0].valueCodeableConcept.coding[0].display "Brand"
extension[0].extension[1].url "mailOrder"
extension[0].extension[1].valueBoolean "false"
extension[0].extension[2].url "costSharing"
extension[0].extension[2].extension[0].url "pharmacyType"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].code #1-month-in-retail
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].display "1 month in network retail"
extension[0].extension[2].extension[1].url "copayAmount"
extension[0].extension[2].extension[1].valueMoney.value 20
extension[0].extension[2].extension[2].url "coinsuranceRate"
extension[0].extension[2].extension[2].valueDecimal "0.2"
extension[0].extension[2].extension[3].url "copayOption"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].display "After Deductible"
extension[0].extension[2].extension[4].url "coinsuranceOption"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].system "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].code #after-deductible
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].display "After Deductible"
extension[1].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension"
extension[1].valueString "http://url/to/health/plan/information"
extension[2].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension"
extension[2].valueString "http://url/to/health/plan/information"
extension[3].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension"
extension[3].valueString "http://url/to/formulary/information"
extension[4].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension"
extension[4].valueString "email@address.com"
extension[5].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension"
extension[5].valueString "PREFERRED"
extension[6].url "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension"
extension[6].valueString "HIOS-PLAN-ID"