DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.0.0 - STU 2
US
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 
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:InsurancePlan;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "PayerInsurancePlanA3004t"];
fhir:Resource.meta [
fhir:Meta.lastUpdated [ fhir:value "2021-08-04T18:36:03.000+00:00"^^xsd:dateTime ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan> ]
];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "extensions" ];
fhir:Narrative.div "<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 \"PayerInsurancePlanA3004t\" Updated \"2021-08-04 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: A3004t</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 A3004t</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/3.1.0/CodeSystem-contactentity-type.html\">Contact entity type</a>#PATINF)</span></p><p><b>telecom</b>: <a href=\"tel:+1(888)555-3004\">+1 (888) 555-3004</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-FormularyD3004t.html\">InsurancePlan/FormularyD3004t</a> \"Sample Medicare Advantage Part D Formulary D3004t\"</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>: 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>: 10 $<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>: 0 %<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>: 10 $<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>: 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>: 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>: 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>: 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>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><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>: Zero cost-share preventative <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>#zero-cost-share-preventative)</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 = '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>: 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: 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>: Zero cost-share preventative <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>#zero-cost-share-preventative)</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 = '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>: 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: 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>: Zero cost-share preventative <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>#zero-cost-share-preventative)</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 = '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>: 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: 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>: Zero cost-share preventative <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>#zero-cost-share-preventative)</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 = '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>: 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: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><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>: 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><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>: 50 $<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>: 0 %<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>: 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><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>: 50 $<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>: 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>: 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><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>: 100 $<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>: 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>: 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><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>: 100 $<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>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><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>: Non-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>#non-preferred-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>: 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>: 70 $<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>: 0 %<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>: Non-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>#non-preferred-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>: 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>: 70 $<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>: 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>: Non-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>#non-preferred-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>: 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>: 140 $<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>: 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>: Non-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>#non-preferred-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>: 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>: 140 $<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>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote><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>: Specialty <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>#specialty)</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>: 100 $<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>: 0 %<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>: Specialty <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>#specialty)</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>: 100 $<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>: 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>: Specialty <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>#specialty)</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>: 200 $<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>: 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>: Specialty <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>#specialty)</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>: 200 $<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>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code % = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>"
];
fhir:InsurancePlan.identifier [
fhir:index 0;
fhir:Identifier.value [ fhir:value "A3004t" ]
];
fhir:InsurancePlan.status [ fhir:value "active"];
fhir:InsurancePlan.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS" ];
fhir:Coding.code [ fhir:value "mediadv" ] ]
];
fhir:InsurancePlan.name [ fhir:value "Sample Medicare Advantage Plan A3004t"];
fhir:InsurancePlan.period [
fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ];
fhir:Period.end [ fhir:value "2021-12-31"^^xsd:date ]
];
fhir:InsurancePlan.coverageArea [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Location/UnitedStatesLocation" ]
];
fhir:InsurancePlan.contact [
fhir:index 0;
fhir:InsurancePlan.contact.purpose [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/contactentity-type" ];
fhir:Coding.code [ fhir:value "PATINF" ] ] ];
fhir:InsurancePlan.contact.telecom [
fhir:index 0;
fhir:ContactPoint.system [ fhir:value "phone" ];
fhir:ContactPoint.value [ fhir:value "+1 (888) 555-3004" ] ]
], [
fhir:index 1;
fhir:InsurancePlan.contact.purpose [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "MARKETING" ] ] ];
fhir:InsurancePlan.contact.name [
fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Plan Marketing Website" ] ];
fhir:InsurancePlan.contact.telecom [
fhir:index 0;
fhir:ContactPoint.system [ fhir:value "url" ];
fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ]
], [
fhir:index 2;
fhir:InsurancePlan.contact.purpose [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "SUMMARY" ] ] ];
fhir:InsurancePlan.contact.name [
fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Drug Plan Benefit Website" ] ];
fhir:InsurancePlan.contact.telecom [
fhir:index 0;
fhir:ContactPoint.system [ fhir:value "url" ];
fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ]
], [
fhir:index 3;
fhir:InsurancePlan.contact.purpose [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "FORMULARY" ] ] ];
fhir:InsurancePlan.contact.name [
fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Drug Plan Formulary Website" ] ];
fhir:InsurancePlan.contact.telecom [
fhir:index 0;
fhir:ContactPoint.system [ fhir:value "url" ];
fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ]
];
fhir:InsurancePlan.coverage [
fhir:index 0;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension" ];
fhir:Extension.valueReference [
fhir:Reference.reference [ fhir:value "InsurancePlan/FormularyD3004t" ] ] ];
fhir:InsurancePlan.coverage.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ];
fhir:Coding.code [ fhir:value "DRUGPOL" ] ] ];
fhir:InsurancePlan.coverage.benefit [
fhir:index 0;
fhir:InsurancePlan.coverage.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insurance-plan-type" ];
fhir:Coding.code [ fhir:value "Drug" ];
fhir:Coding.display [ fhir:value "Drug" ] ] ] ]
];
fhir:InsurancePlan.plan [
fhir:index 0;
fhir:InsurancePlan.plan.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insurance-plan-type" ];
fhir:Coding.code [ fhir:value "Drug" ];
fhir:Coding.display [ fhir:value "Drug" ] ] ];
fhir:InsurancePlan.plan.specificCost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-in-retail" ];
fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "generic" ];
fhir:Coding.display [ fhir:value "Generic" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-out-retail" ];
fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "generic" ];
fhir:Coding.display [ fhir:value "Generic" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 2;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-in-retail" ];
fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "generic" ];
fhir:Coding.display [ fhir:value "Generic" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 3;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-out-retail" ];
fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "generic" ];
fhir:Coding.display [ fhir:value "Generic" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 4;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-in-retail" ];
fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ];
fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 5;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-out-retail" ];
fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ];
fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 6;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-in-retail" ];
fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ];
fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 7;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-out-retail" ];
fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ];
fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 8;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-in-retail" ];
fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "preferred-brand" ];
fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 9;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-out-retail" ];
fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "preferred-brand" ];
fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 10;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-in-retail" ];
fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "preferred-brand" ];
fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 11;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-out-retail" ];
fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "preferred-brand" ];
fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 12;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-in-retail" ];
fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "non-preferred-brand" ];
fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 13;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-out-retail" ];
fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "non-preferred-brand" ];
fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 14;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-in-retail" ];
fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "non-preferred-brand" ];
fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "140"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 15;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-out-retail" ];
fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "non-preferred-brand" ];
fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "140"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 16;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-in-retail" ];
fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "specialty" ];
fhir:Coding.display [ fhir:value "Specialty" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 17;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "1-month-out-retail" ];
fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "specialty" ];
fhir:Coding.display [ fhir:value "Specialty" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 18;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-in-retail" ];
fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "specialty" ];
fhir:Coding.display [ fhir:value "Specialty" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [
fhir:index 19;
fhir:InsurancePlan.plan.specificCost.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "3-month-out-retail" ];
fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "specialty" ];
fhir:Coding.display [ fhir:value "Specialty" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost [
fhir:index 0;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "Copay" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "no-charge" ];
fhir:Coding.display [ fhir:value "No Charge" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ];
fhir:Quantity.unit [ fhir:value "$" ];
fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
fhir:Quantity.code [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "coinsurance" ];
fhir:Coding.display [ fhir:value "Coinsurance" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ];
fhir:Coding.code [ fhir:value "after-deductible" ];
fhir:Coding.display [ fhir:value "After Deductible" ] ] ];
fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "%" ] ] ] ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.
IG © 2022+ HL7 Pharmacy Working Group. Package hl7.fhir.us.davinci-drug-formulary#2.0.0 based on FHIR 4.0.1. Generated 2022-08-25
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