This Section describes the expected capabilities of the US Drug Formulary Server actor which is responsible for providing responses to the queries submitted by the US Drug Formulary Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Drug Formulary Server are defined.

Accesses the Code of a Basis resource to find a FormularyItem

Accesses the Drug Tier of a FormularyItem

Accesses the formulary reference of a FormularyItem

Accesses the last updated date of a FormularyItem

Accesses the active period of a FormularyItem

Accesses the Pharmacy Benefit Type of a FormularyItem

Accesses the status of a FormularyItem

Accesses the subject FormularyDrug (MedicationKnowledge) reference of a FormularyItem

Search InsurancePlan by coverage location.

Accesses the coverage type of an InsurancePlan

Accesses the Coverage Formulary Reference of an InsurancePlan

Accesses the business identifier of an InsurancePlan

Accesses the last updated date of an InsurancePlan

Accesses the name of an InsurancePlan

Accesses the active period of an InsurancePlan

Accesses the status of an InsurancePlan

Accesses the Type of an InsurancePlan

Accesses the status of a FormularyDrug

Accesses the dose form of a FormularyDrug

Accesses the Drug Name of a FormularyDrug

Accesses the last updated date of a FormularyItem

Accesses the status of a FormularyDrug

The Formulary provides general information about a formulary and acts as an organizing construct that associated FormularyItem resources point to. The Formulary combined with its associated FormularyItem and FormularyDrug resources represent a formulary list that includes the set of drugs covered and the requirements and limitations of the coverage.

A GraphDefinition defining a graph of resources to return in a query for a Formulary related Bulk Data request.

Drug information which may be part of a formulary including its RxNorm code and dose form.

A resource that describes a drug’s relationship to a drug plan, including drug tier, prior authorization requirements, and more. The set of FormularyItem resources associated with a particular drug plan represents the drug plans formulary.

A Location describing a geographic region or are where the insurance plan coverage is available.

The Payer InsurancePlan that defines the health insurance product, which include coverage benefits that are offered, and additional information about the offering, such as a coverage area, contact information, brochure locations, etc. The health insurance product offers one or more types of coverage, each of which may define a plan of covered benefits with the particular cost sharing structure offered to a consumer. Health insurance plans that include drug coverage reference a formulary that provides details about drugs that are covered under the plan including requirements and limitations of the coverage specific to each drug.

A GraphDefinition defining a graph of resources to return in a query for a Formulary related Payer Insurance Plan Bulk Data request.

Additional drug coverage information that may include conditional coverage requirements such as a diagnosis pre-requisite, additional drug specific cost sharing information, or other coverage details not otherwise indicated.

The period for which this item is available on the formulary. Drugs may appear on a formulary, but not considered “active” for the current year.

A boolean indicating whether the formulary item is currently available under the formulary. Drugs may appear on a formulary, but not considered “active” for the current year. Drugs may also be removed during the course of a plan year.

A code that describes the coverage status of a drug in a health plan (e.g., preferred generic, specialty, etc.)

Reference to the formulary this item belongs to.

A CodeableConcept indicating the pharmacy benefit type the formulary drug is available through the associated plan. This pharmacy benefit type is specific to the FormularyDrug and indicates which of the pharmacy benefit type from the plan applies to the particular formulary drug.

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug.

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug for new starts only. (Only include if PriorAuthorization = true)

A Boolean indication of whether the coverage plan imposes a quantity limit on this drug.

A detailed definition of the quantity limits the coverage plan imposes on this drug. These limit details may include (potentially including a rolling dispense limit, maximum daily, or therapy days for a period of time. (Only include if QuantityLimit = true)

A boolean indicating whether the coverage plan imposes a step therapy requirement on this drug meaning another drug may need to be tried beforehand.

A boolean indicating whether the coverage plan imposes a step therapy requirement on this drug meaning another drug may need to be tried beforehand for new starts only (Not required if patient has previously met step therapy requirements). (Only include if StepTherapyLimit = true)

Benefit type of cost

Qualifier for coinsurance rate

Qualifier of copay amount

The drug tier of a particular medication in a health plan. The base set are examples. Each plan may have its own controlled vocabulary.

Types of insurance items

Pharmacy benefit types. Each payer will have its own controlled vocabulary.

Type of plan contact

Semantic Drug Form Group codes with Term Types (TTY) of Semantic Clinical Drug Form (SCDG) and Semantic Branded Drug Form Group (SBDG)

Semantic Drug codes with Term Types (TTY) of Semantic Clinical Drug (SCD), Semantic Branded Drug (SBD), Generic Pack (GPCK), or Branded Pack (BPCK)

Types of out of pockets costs associated with the benefit

Codes for qualifier of copay amount

Codes to represent the drug tier of a particular medication in a health plan. Base set are examples. Each plan may have its own controlled vocabulary.

Types of insurance items

Codes for pharmacy benefit types. Each payer will have its own controlled vocabulary.

Type of plan contact

Formulary D1002

Formulary D3001

Formulary D3002

Formulary D3004t

Formulary Drug 1000091

Formulary Drug 1049640

Formulary Drug 1541228

Formulary Drug 209459

Formulary Drug 284520

A GraphDefinition of Formulary.

Formulary Item for Formulary D1002 Drug 1000091

Formulary Item for Formulary D1002 Drug 1049640

Formulary Item for Formulary D1002 Drug 209459

Formulary Item for Formulary D1002 Drug 284520

Formulary Item for Insurance Formulary D3001 Drug 1000091

Formulary Item for Insurance Formulary D3002 Drug 1000091

Formulary Item for Insurance Formulary D3004t Drug 1049640

Payer Insurance Plan A1002

Payer Insurance Plan A3001

Payer Insurance Plan A3002

Payer Insurance Plan A3004t

A GraphDefinition of PayerInsurancePlan.

State of CT Area

United States Area