DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU 3 (ci-build) United States of America flag

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

: FormularyItem-D3004t-1049640 - JSON Representation

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{
  "resourceType" : "Basic",
  "id" : "FormularyItem-D3004t-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><b>Generated Narrative: Basic </b><a name=\"FormularyItem-D3004t-1049640\"> </a><a name=\"hcFormularyItem-D3004t-1049640\"> </a></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\">ResourceBasic &quot;FormularyItem-D3004t-1049640&quot; Updated&quot;2021-08-22 18:36:03+0000&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-FormularyItem.html\">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD3004t.html\">InsurancePlan/FormularyD3004t</a> &quot;Sample Medicare Advantage Part D Formulary D3004t&quot;</p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</b>: 3 month out of network retail <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE.html\">Codes for pharmacy benefit types</a>#3-month-out-retail)</span></p><p><b>Drug Tier ID</b>: Preferred Brand <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-DrugTierCS-TEMPORARY-TRIAL-USE.html\">Codes for medication drug tiers in health plans</a>#preferred-brand)</span></p><p><b>Availability Period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><p><b>code</b>: Formulary Item <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-usdf-InsuranceItemTypeCS.html\">Codes for insurance item type</a>#formulary-item)</span></p><p><b>subject</b>: <a href=\"MedicationKnowledge-FormularyDrug-1049640.html\">MedicationKnowledge/FormularyDrug-1049640</a></p></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
      "valueReference" : {
        🔗 "reference" : "InsurancePlan/FormularyD3004t"
      }
    },
    {
      "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" : "preferred-brand",
            "display" : "Preferred 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
    }
  ],
  "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"
  }
}