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

: PayerInsurancePlanA1002 - XML Representation

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<InsurancePlan xmlns="http://hl7.org/fhir">
  <id value="PayerInsurancePlanA1002"/>
  <meta>
    <lastUpdated value="2021-08-22T18:36:03.000+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: InsurancePlan</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 InsurancePlan "PayerInsurancePlanA1002" Updated "2021-08-22 06:36:03+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: A1002</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/CodeSystem-InsuranceProductTypeCS.html">Insurance Product Type</a>#mediadv)</span></p><p><b>name</b>: Sample Medicare Advantage Plan A1002</p><p><b>period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>coverageArea</b>: <a href="Location-StateOfCTLocation.html">Location/StateOfCTLocation</a> "State of CT 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/3.1.0/CodeSystem-contactentity-type.html">Contact entity type</a>#PATINF)</span></p><p><b>telecom</b>: <a href="tel:+1(888)555-1002">+1 (888) 555-1002</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-FormularyD1002.html">InsurancePlan/FormularyD1002</a> "Sample Medicare Advantage Part D Formulary D1002"</p><p><b>type</b>: drug policy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-v3-ActCode.html">ActCode</a>#DRUGPOL)</span></p><h3>Benefits</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td></tr><tr><td>*</td><td>Drug <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/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/3.1.0/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>: 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>#brand)</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>: 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>: 20 $<span style="background: LightGoldenRodYellow"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</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>: 20 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>
  </text>
  <identifier>
    <value value="A1002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system
              value="http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS"/>
      <code value="mediadv"/>
    </coding>
  </type>
  <name value="Sample Medicare Advantage Plan A1002"/>
  <period>
    <start value="2021-01-01"/>
    <end value="2021-12-31"/>
  </period>
  <coverageArea>
    <reference value="Location/StateOfCTLocation"/>
  </coverageArea>
  <contact>
    <purpose>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/contactentity-type"/>
        <code value="PATINF"/>
      </coding>
    </purpose>
    <telecom>
      <system value="phone"/>
      <value value="+1 (888) 555-1002"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="MARKETING"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Plan Marketing Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="SUMMARY"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Drug Plan Benefit Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="FORMULARY"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Drug Plan Formulary Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <coverage>
    <extension
               url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension">
      <valueReference>
        <reference value="InsurancePlan/FormularyD1002"/>
      </valueReference>
    </extension>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
        <code value="DRUGPOL"/>
      </coding>
    </type>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/insurance-plan-type"/>
          <code value="Drug"/>
          <display value="Drug"/>
        </coding>
      </type>
    </benefit>
  </coverage>
  <plan>
    <type>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/insurance-plan-type"/>
        <code value="Drug"/>
        <display value="Drug"/>
      </coding>
    </type>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
          <code value="1-month-in-retail"/>
          <display value="1 month in network retail"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"/>
            <code value="brand"/>
            <display value="Brand"/>
          </coding>
        </type>
        <cost>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
              <code value="copay"/>
              <display value="Copay"/>
            </coding>
          </type>
          <qualifiers>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
              <code value="after-deductible"/>
              <display value="After Deductible"/>
            </coding>
          </qualifiers>
          <value>
            <value value="20"/>
            <unit value="$"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
              <code value="coinsurance"/>
              <display value="Coinsurance"/>
            </coding>
          </type>
          <qualifiers>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
              <code value="after-deductible"/>
              <display value="After Deductible"/>
            </coding>
          </qualifiers>
          <value>
            <value value="20"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
  </plan>
</InsurancePlan>