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 - TTL Representation

Page standards status: Trial-use

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@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:CodeSystem ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
fhir:value [ fhir:v "phx" ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ] ;
fhir:value [
fhir:v "trial-use" ;
      ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ] ;
fhir:value [
fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/ImplementationGuide/hl7.fhir.us.davinci-drug-formulary"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/ImplementationGuide/hl7.fhir.us.davinci-drug-formulary>         ]       ] )     ]
  ] ) ; # 
  fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI] ; # 
  fhir:version [ fhir:v "2.1.0"] ; # 
  fhir:name [ fhir:v "CostShareOptionCS"] ; # 
  fhir:title [ fhir:v "Codes qualifying the type of cost share amount"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v "false"^^xsd:boolean] ; # 
  fhir:date [ fhir:v "2024-06-06T20:54:07+00:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "HL7 International / Pharmacy"] ; # 
  fhir:contact ( [
fhir:name [ fhir:v "HL7 International / Pharmacy" ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/medication" ]     ] [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "pharmacy@lists.HL7.org" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "Codes for qualifier of copay amount"] ; # 
  fhir:jurisdiction ( [
    ( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ]     ] )
  ] ) ; # 
  fhir:caseSensitive [ fhir:v "true"^^xsd:boolean] ; # 
  fhir:content [ fhir:v "complete"] ; # 
  fhir:count [ fhir:v "8"^^xsd:nonNegativeInteger] ; # 
  fhir:concept ( [
fhir:code [ fhir:v "after-deductible" ] ;
fhir:display [ fhir:v "After Deductible" ] ;
fhir:definition [ fhir:v "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)." ]
  ] [
fhir:code [ fhir:v "before-deductible" ] ;
fhir:display [ fhir:v "Before Deductible" ] ;
fhir:definition [ fhir:v "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)." ]
  ] [
fhir:code [ fhir:v "no-charge" ] ;
fhir:display [ fhir:v "No Charge" ] ;
fhir:definition [ fhir:v "No cost sharing is charged (this indicates that this benefit is not subject to the deductible)." ]
  ] [
fhir:code [ fhir:v "no-charge-after-deductible" ] ;
fhir:display [ fhir:v "No Charge After Deductible" ] ;
fhir:definition [ fhir:v "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)." ]
  ] [
fhir:code [ fhir:v "charge" ] ;
fhir:display [ fhir:v "Charge" ] ;
fhir:definition [ fhir:v "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)." ]
  ] [
fhir:code [ fhir:v "coinsurance-not-applicable" ] ;
fhir:display [ fhir:v "Coinsurance Not Applicable" ] ;
fhir:definition [ fhir:v "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)." ]
  ] [
fhir:code [ fhir:v "copay-not-applicable" ] ;
fhir:display [ fhir:v "Copay Not Applicable" ] ;
fhir:definition [ fhir:v "Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'." ]
  ] [
fhir:code [ fhir:v "deductible-waived" ] ;
fhir:display [ fhir:v "Deductible Waived" ] ;
fhir:definition [ fhir:v "The consumer pays the cost share amount with deductible requirement waived." ]
  ] ) . #