DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.0 - STU 2 US

This page is part of the US Drug Formulary (v2.0.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Basic: FormularyItem-D1002-1049640

Generated Narrative: Basic

Resource Basic "FormularyItem-D1002-1049640" Updated "2021-08-22 06:36:03+0000"

Profile: Formulary Item

Formulary Reference: InsurancePlan/FormularyD1002 "Sample Medicare Advantage Part D Formulary D1002"

Availability Status: active

Pharmacy Benefit Type: 3 month out of network retail (Codes for pharmacy benefit types#3-month-out-retail)

Drug Tier ID: Brand (Codes for medication drug tiers in health plans#brand)

Availability Period: 2021-01-01 --> 2021-12-31

Prior Authorization: true

Prior Authorization New Starts Only: true

Step Therapy Limit: true

Step Therapy Limit New Starts Only: false

Quantity Limit: true

Quantity Limit Detail

value: Count 60 times, Do Once per 30 days

value: 2

value: Count 1 times, Do Once per 180 days

Additional Coverage Information: Prior Authorization required only with a newly started medication Step Therapy required.

code: Formulary Item (Codes for insurance item type#formulary-item)

subject: MedicationKnowledge/FormularyDrug-1049640