DaVinci Payer Data Exchange (PDex) US Drug Formulary, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pdex-formulary/ and changes regularly. See the Directory of published versions

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: FormularyItem-D1002-1049640 - JSON Representation

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{
  "resourceType" : "Basic",
  "id" : "FormularyItem-D1002-1049640",
  "meta" : {
    "lastUpdated" : "2021-08-22T18:36:03.000+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Basic FormularyItem-D1002-1049640</b></p><a name=\"FormularyItem-D1002-1049640\"> </a><a name=\"hcFormularyItem-D1002-1049640\"> </a><a name=\"FormularyItem-D1002-1049640-en-US\"> </a><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\">Last updated: 2021-08-22 18:36:03+0000</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-FormularyItem.html\">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD1002.html\">InsurancePlan Sample Medicare Advantage Part D Formulary D1002</a></p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><p><b>Drug Tier ID</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE brand}\">Brand</span></p><p><b>Availability Period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><blockquote><p><b>Quantity Limit Detail</b></p><ul><li>Rolling: Count 60  times, Once per 30 days</li><li>MaximumDaily: 2</li><li>DaysSupply: Count 1  times, Once per 180 days</li></ul></blockquote><p><b>Additional Coverage Information</b>: </p><div><p>Prior Authorization required only with a newly started medication\nStep Therapy required.</p>\n</div><p><b>code</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS formulary-item}\">Formulary Item</span></p><p><b>subject</b>: <a href=\"MedicationKnowledge-FormularyDrug-1049640.html\">MedicationKnowledge acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]</a></p></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
      "valueReference" : {
        🔗 "reference" : "InsurancePlan/FormularyD1002"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityStatus-extension",
      "valueCode" : "active"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyBenefitType-extension",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
            "code" : "3-month-out-retail",
            "display" : "3 month out of network retail"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
            "code" : "brand",
            "display" : "Brand"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityPeriod-extension",
      "valuePeriod" : {
        "start" : "2021-01-01",
        "end" : "2021-12-31"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorization-extension",
      "valueBoolean" : true
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorizationNewStartsOnly-extension",
      "valueBoolean" : true
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimit-extension",
      "valueBoolean" : true
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimitNewStartsOnly-extension",
      "valueBoolean" : false
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimit-extension",
      "valueBoolean" : true
    },
    {
      "extension" : [
        {
          "url" : "Rolling",
          "valueTiming" : {
            "repeat" : {
              "count" : 60,
              "period" : 30,
              "periodUnit" : "d"
            }
          }
        },
        {
          "url" : "MaximumDaily",
          "valueQuantity" : {
            "value" : 2
          }
        },
        {
          "url" : "DaysSupply",
          "valueTiming" : {
            "repeat" : {
              "boundsDuration" : {
                "value" : 365,
                "system" : "http://unitsofmeasure.org",
                "code" : "d"
              },
              "count" : 1,
              "period" : 180,
              "periodUnit" : "d"
            }
          }
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimitDetail-extension"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AdditionalCoverageInformation-extension",
      "valueMarkdown" : "Prior Authorization required only with a newly started medication\nStep Therapy required."
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS",
        "code" : "formulary-item",
        "display" : "Formulary Item"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "MedicationKnowledge/FormularyDrug-1049640"
  }
}