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 - XML Representation

Page standards status: Trial-use

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