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

: FormularyItem-D3004t-1049640 - XML Representation

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<Basic xmlns="http://hl7.org/fhir">
  <id value="FormularyItem-D3004t-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></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 "FormularyItem-D3004t-1049640" Updated "2021-08-22 06:36:03+0000" </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-FormularyD3004t.html">InsurancePlan/FormularyD3004t</a> "Sample Medicare Advantage Part D Formulary D3004t"</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>: Preferred 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>#preferred-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><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/FormularyD3004t"/>
    </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="preferred-brand"/>
        <display value="Preferred 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>
  <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>