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

: Codes qualifying the type of cost share amount - JSON Representation

Page standards status: Trial-use

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{
  "resourceType" : "CodeSystem",
  "id" : "usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">after-deductible<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-after-deductible\"> </a></td><td>After Deductible</td><td>The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the cost-share amount (this indicates that this benefit is subject to the deductible).</td></tr><tr><td style=\"white-space:nowrap\">before-deductible<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-before-deductible\"> </a></td><td>Before Deductible</td><td>The consumer first pays the cost share amount, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible).</td></tr><tr><td style=\"white-space:nowrap\">no-charge<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-no-charge\"> </a></td><td>No Charge</td><td>No cost sharing is charged (this indicates that this benefit is not subject to the deductible).</td></tr><tr><td style=\"white-space:nowrap\">no-charge-after-deductible<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-no-charge-after-deductible\"> </a></td><td>No Charge After Deductible</td><td>The consumer first pays the deductible, and after the deductible is met, no cost share amount is charged (this indicates that this benefit is subject to the deductible).</td></tr><tr><td style=\"white-space:nowrap\">charge<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-charge\"> </a></td><td>Charge</td><td>The consumer always pays just the cost share amount and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible).</td></tr><tr><td style=\"white-space:nowrap\">coinsurance-not-applicable<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-coinsurance-not-applicable\"> </a></td><td>Coinsurance Not Applicable</td><td>The consumer pays only a copay. Note: When using Not Applicable for coinsurance, Not Applicable cannot also be used for copay (unless the drug tier type is Medical Service Drugs).</td></tr><tr><td style=\"white-space:nowrap\">copay-not-applicable<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-copay-not-applicable\"> </a></td><td>Copay Not Applicable</td><td>Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'.</td></tr><tr><td style=\"white-space:nowrap\">deductible-waived<a name=\"usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE-deductible-waived\"> </a></td><td>Deductible Waived</td><td>The consumer pays the cost share amount with deductible requirement waived.</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "phx"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-drug-formulary/ImplementationGuide/hl7.fhir.us.davinci-drug-formulary"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
  "version" : "2.1.0",
  "name" : "CostShareOptionCS",
  "title" : "Codes qualifying the type of cost share amount",
  "status" : "active",
  "experimental" : false,
  "date" : "2024-06-06T20:54:07+00:00",
  "publisher" : "HL7 International / Pharmacy",
  "contact" : [
    {
      "name" : "HL7 International / Pharmacy",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/medication"
        },
        {
          "system" : "email",
          "value" : "pharmacy@lists.HL7.org"
        }
      ]
    }
  ],
  "description" : "Codes for qualifier of copay amount",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "caseSensitive" : true,
  "content" : "complete",
  "count" : 8,
  "concept" : [
    {
      "code" : "after-deductible",
      "display" : "After Deductible",
      "definition" : "The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the cost-share amount (this indicates that this benefit is subject to the deductible)."
    },
    {
      "code" : "before-deductible",
      "display" : "Before Deductible",
      "definition" : "The consumer first pays the cost share amount, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible)."
    },
    {
      "code" : "no-charge",
      "display" : "No Charge",
      "definition" : "No cost sharing is charged (this indicates that this benefit is not subject to the deductible)."
    },
    {
      "code" : "no-charge-after-deductible",
      "display" : "No Charge After Deductible",
      "definition" : "The consumer first pays the deductible, and after the deductible is met, no cost share amount is charged (this indicates that this benefit is subject to the deductible)."
    },
    {
      "code" : "charge",
      "display" : "Charge",
      "definition" : "The consumer always pays just the cost share amount and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible)."
    },
    {
      "code" : "coinsurance-not-applicable",
      "display" : "Coinsurance Not Applicable",
      "definition" : "The consumer pays only a copay. Note: When using Not Applicable for coinsurance, Not Applicable cannot also be used for copay (unless the drug tier type is Medical Service Drugs)."
    },
    {
      "code" : "copay-not-applicable",
      "display" : "Copay Not Applicable",
      "definition" : "Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'."
    },
    {
      "code" : "deductible-waived",
      "display" : "Deductible Waived",
      "definition" : "The consumer pays the cost share amount with deductible requirement waived."
    }
  ]
}