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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• Detailed Descriptions
• Mappings
• Examples
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• TTL

Resource Profile: Payer Insurance Plan

The Payer InsurancePlan that defines the health insurance product, which include coverage benefits that are offered, and additional information about the offering, such as a coverage area, contact information, brochure locations, etc. The health insurance product offers one or more types of coverage, each of which may define a plan of covered benefits with the particular cost sharing structure offered to a consumer. Health insurance plans that include drug coverage reference a formulary that provides details about drugs that are covered under the plan including requirements and limitations of the coverage specific to each drug.

Usage:

• Examples for this Resource Profile: Sample Medicare Advantage Plan A1002, Sample Medicare Advantage Plan A3001, Sample Medicare Advantage Plan A3002 and Sample Medicare Advantage Plan A3004t

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
meta
lastUpdated	S	1..1	instant	When the resource version last changed
identifier	S	1..*	Identifier	Business Identifier for Product
status	S	1..1	code	draft | active | retired | unknown
type	S	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	S	0..1	string	Official name
period	S	0..1	Period	When the product is available
coverageArea	S	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
text	S	0..1	string	Text representation of the full name
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
system	S	0..1	code	phone | fax | email | pager | url | sms | other
value	S	0..1	string	The actual contact point details
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
type	S	1..1	CodeableConcept	Type of coverage
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
plan:drug-plan	S	1..*	BackboneElement	Drug plan
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value		0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision)
value	S	1..1	decimal	Numerical value (with implicit precision)
system		0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code		0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
value
system		0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code		0..1	code	Coded form of the unit Required Pattern: %
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
meta	Σ	0..1	Meta	Metadata about the resource
lastUpdated	SΣ	1..1	instant	When the resource version last changed
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..*	Identifier	Business Identifier for Product
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	SΣC	0..1	string	Official name
period	S	0..1	Period	When the product is available
coverageArea	SΣ	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
use	?!Σ	0..1	code	usual | official | temp | nickname | anonymous | old | maiden Binding: NameUse (required): The use of a human name.
text	SΣ	0..1	string	Text representation of the full name
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
system	SΣC	0..1	code	phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point.
value	SΣ	0..1	string	The actual contact point details
use	?!Σ	0..1	code	home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point.
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of coverage
benefit		1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
plan:drug-plan	S	1..*	BackboneElement	Drug plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value	C	0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision) mqty-1: There SHALL be a code if there is a value and it SHALL be an expression of currency. If system is present, it SHALL be ISO 4217 (system = "urn:iso:std:iso:4217" - currency). qty-3: If a code for the unit is present, the system SHALL also be present
value	SΣ	1..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code	Σ	0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.contact.name.use	required	NameUse http://hl7.org/fhir/ValueSet/name-use|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.system	required	ContactPointSystem http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.use	required	ContactPointUse http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1 from the FHIR Standard
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..*	Identifier	Business Identifier for Product
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	SΣC	0..1	string	Official name
alias		0..*	string	Alternate names
period	S	0..1	Period	When the product is available
ownedBy	Σ	0..1	Reference(Organization)	Plan issuer
administeredBy	Σ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | nickname | anonymous | old | maiden Binding: NameUse (required): The use of a human name.
text	SΣ	0..1	string	Text representation of the full name
family	Σ	0..1	string	Family name (often called 'Surname')
given	Σ	0..*	string	Given names (not always 'first'). Includes middle names This repeating element order: Given Names appear in the correct order for presenting the name
prefix	Σ	0..*	string	Parts that come before the name This repeating element order: Prefixes appear in the correct order for presenting the name
suffix	Σ	0..*	string	Parts that come after the name This repeating element order: Suffixes appear in the correct order for presenting the name
period	Σ	0..1	Period	Time period when name was/is in use
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣC	0..1	code	phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point.
value	SΣ	0..1	string	The actual contact point details
use	?!Σ	0..1	code	home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point.
rank	Σ	0..1	positiveInt	Specify preferred order of use (1 = highest)
period	Σ	0..1	Period	Time period when the contact point was/is in use
address		0..1	Address	Visiting or postal addresses for the contact
endpoint		0..*	Reference(Endpoint)	Technical endpoint
network		0..*	Reference(Organization)	What networks are Included
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of coverage
network		0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
id		0..1	string	Unique id for inter-element referencing
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
network		0..*	Reference(Organization)	What networks provide coverage
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
coverageArea	Σ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost		0..*	BackboneElement	Overall costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of cost
groupSize		0..1	positiveInt	Number of enrollees
cost		0..1	Money	Cost value
comment		0..1	string	Additional cost information
specificCost		0..*	BackboneElement	Specific costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	General category of benefit
benefit		0..*	BackboneElement	Benefits list
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of specific benefit
cost		0..*	BackboneElement	List of the costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost
value		0..1	Quantity	The actual cost value
plan:drug-plan	S	1..*	BackboneElement	Drug plan
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
coverageArea	Σ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
generalCost		0..*	BackboneElement	Overall costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of cost
groupSize		0..1	positiveInt	Number of enrollees
cost		0..1	Money	Cost value
comment		0..1	string	Additional cost information
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value	C	0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision) mqty-1: There SHALL be a code if there is a value and it SHALL be an expression of currency. If system is present, it SHALL be ISO 4217 (system = "urn:iso:std:iso:4217" - currency). qty-3: If a code for the unit is present, the system SHALL also be present
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code	Σ	0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
value		0..1	Quantity	The actual cost value
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit Required Pattern: %
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
InsurancePlan.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.contact.name.use	required	NameUse http://hl7.org/fhir/ValueSet/name-use|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.system	required	ContactPointSystem http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.use	required	ContactPointUse http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1 from the FHIR Standard
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard

This structure is derived from InsurancePlan

Summary

Mandatory: 15 elements(2 nested mandatory elements)
Must-Support: 30 elements

Structures

This structure refers to these other structures:

• Insurance Plan Location (http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-InsurancePlanLocation)
• MoneyQuantity (http://hl7.org/fhir/StructureDefinition/MoneyQuantity)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of InsurancePlan.coverage
• The element 1 is sliced based on the value of InsurancePlan.coverage.benefit
• The element 1 is sliced based on the value of InsurancePlan.plan
• The element 1 is sliced based on the value of InsurancePlan.plan.specificCost.benefit.cost

Differential View

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
meta
lastUpdated	S	1..1	instant	When the resource version last changed
identifier	S	1..*	Identifier	Business Identifier for Product
status	S	1..1	code	draft | active | retired | unknown
type	S	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	S	0..1	string	Official name
period	S	0..1	Period	When the product is available
coverageArea	S	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
text	S	0..1	string	Text representation of the full name
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
system	S	0..1	code	phone | fax | email | pager | url | sms | other
value	S	0..1	string	The actual contact point details
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
type	S	1..1	CodeableConcept	Type of coverage
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
plan:drug-plan	S	1..*	BackboneElement	Drug plan
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value		0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision)
value	S	1..1	decimal	Numerical value (with implicit precision)
system		0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code		0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
value
system		0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code		0..1	code	Coded form of the unit Required Pattern: %
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
meta	Σ	0..1	Meta	Metadata about the resource
lastUpdated	SΣ	1..1	instant	When the resource version last changed
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..*	Identifier	Business Identifier for Product
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	SΣC	0..1	string	Official name
period	S	0..1	Period	When the product is available
coverageArea	SΣ	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
use	?!Σ	0..1	code	usual | official | temp | nickname | anonymous | old | maiden Binding: NameUse (required): The use of a human name.
text	SΣ	0..1	string	Text representation of the full name
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
system	SΣC	0..1	code	phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point.
value	SΣ	0..1	string	The actual contact point details
use	?!Σ	0..1	code	home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point.
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of coverage
benefit		1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
plan:drug-plan	S	1..*	BackboneElement	Drug plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value	C	0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision) mqty-1: There SHALL be a code if there is a value and it SHALL be an expression of currency. If system is present, it SHALL be ISO 4217 (system = "urn:iso:std:iso:4217" - currency). qty-3: If a code for the unit is present, the system SHALL also be present
value	SΣ	1..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code	Σ	0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.contact.name.use	required	NameUse http://hl7.org/fhir/ValueSet/name-use|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.system	required	ContactPointSystem http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.use	required	ContactPointUse http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1 from the FHIR Standard
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..*	Identifier	Business Identifier for Product
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Product type Binding: Insurance Product Type VS (extensible)
name	SΣC	0..1	string	Official name
alias		0..*	string	Alternate names
period	S	0..1	Period	When the product is available
ownedBy	Σ	0..1	Reference(Organization)	Plan issuer
administeredBy	Σ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Insurance Plan Location)	Where product applies
contact		0..*	BackboneElement	Contact information for the Insurance Plan including URLs for brochure and formulary information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
purpose		0..1	CodeableConcept	The type of contact Binding: Type of plan contact (extensible)
name	S	0..1	HumanName	A name associated with the contact
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | nickname | anonymous | old | maiden Binding: NameUse (required): The use of a human name.
text	SΣ	0..1	string	Text representation of the full name
family	Σ	0..1	string	Family name (often called 'Surname')
given	Σ	0..*	string	Given names (not always 'first'). Includes middle names This repeating element order: Given Names appear in the correct order for presenting the name
prefix	Σ	0..*	string	Parts that come before the name This repeating element order: Prefixes appear in the correct order for presenting the name
suffix	Σ	0..*	string	Parts that come after the name This repeating element order: Suffixes appear in the correct order for presenting the name
period	Σ	0..1	Period	Time period when name was/is in use
telecom	S	0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣC	0..1	code	phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point.
value	SΣ	0..1	string	The actual contact point details
use	?!Σ	0..1	code	home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point.
rank	Σ	0..1	positiveInt	Specify preferred order of use (1 = highest)
period	Σ	0..1	Period	Time period when the contact point was/is in use
address		0..1	Address	Visiting or postal addresses for the contact
endpoint		0..*	Reference(Endpoint)	Technical endpoint
network		0..*	Reference(Organization)	What networks are Included
Slices for coverage	S	1..*	BackboneElement	Coverage details Slice: Unordered, Open by pattern:type
coverage:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of coverage
network		0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
coverage:drug-coverage	S	1..*	BackboneElement	Coverage details
id		0..1	string	Unique id for inter-element referencing
Slices for extension	S	1..*	Extension	Extension Slice: Unordered, Open by value:url
usdf-FormularyReference-extension	S	1..*	Reference(Formulary)	Formulary Reference URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: DRUGPOL
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
network		0..*	Reference(Organization)	What networks provide coverage
Slices for benefit		1..*	BackboneElement	List of benefits Slice: Unordered, Open by pattern:type
benefit:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: InsurancePlanType (1.0.0) (extensible)
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
benefit:drug-plan	S	1..*	BackboneElement	List of benefits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Benefit limits
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
Slices for plan	S	1..*	BackboneElement	Plan details Slice: Unordered, Open by pattern:type
plan:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type		0..1	CodeableConcept	Type of plan Binding: InsurancePlanType (1.0.0) (extensible)
coverageArea	Σ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost		0..*	BackboneElement	Overall costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of cost
groupSize		0..1	positiveInt	Number of enrollees
cost		0..1	Money	Cost value
comment		0..1	string	Additional cost information
specificCost		0..*	BackboneElement	Specific costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	General category of benefit
benefit		0..*	BackboneElement	Benefits list
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of specific benefit
cost		0..*	BackboneElement	List of the costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost
value		0..1	Quantity	The actual cost value
plan:drug-plan	S	1..*	BackboneElement	Drug plan
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type		1..1	CodeableConcept	Type of plan Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
version		1..1	string	Version of the system - if relevant Fixed Value: 2.0.0
code		1..1	code	Symbol in syntax defined by the system Fixed Value: drug
display		1..1	string	Representation defined by the system Fixed Value: Drug
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
coverageArea	Σ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	Pharmacy benefit types that are part of the drug plan
generalCost		0..*	BackboneElement	Overall costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Type of cost
groupSize		0..1	positiveInt	Number of enrollees
cost		0..1	Money	Cost value
comment		0..1	string	Additional cost information
specificCost	S	1..*	BackboneElement	Pharmacy benefit type specific cost
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Pharmacy Benefit Type Binding: Pharmacy benefit types (extensible)
benefit	S	1..*	BackboneElement	Drug tier benefit
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of specific benefit Binding: Drug tier of medication in health plan (extensible)
Slices for cost	S	1..*	BackboneElement	List of the costs Slice: Unordered, Open by pattern:type
cost:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Binding: Benefit type of cost (extensible)
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers	S	1..1	CodeableConcept	Additional information about the cost
value	S	0..1	Quantity	The actual cost value
cost:copay	S	0..1	BackboneElement	Copay costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: copay
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier of copay amount (required)
value	C	0..1	MoneyQuantity	An amount of money. With regard to precision, see [Decimal Precision](datatypes.html#precision) mqty-1: There SHALL be a code if there is a value and it SHALL be an expression of currency. If system is present, it SHALL be ISO 4217 (system = "urn:iso:std:iso:4217" - currency). qty-3: If a code for the unit is present, the system SHALL also be present
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: urn:iso:std:iso:4217
code	Σ	0..1	code	Coded form of the unit Required Pattern: USD
cost:coinsurance	S	0..1	BackboneElement	Coinsurance costs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of cost Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: coinsurance
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
applicability		0..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers		0..*	CodeableConcept	Additional information about the cost Binding: Qualifier for coinsurance rate (required)
value		0..1	Quantity	The actual cost value
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit Required Pattern: %
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
InsurancePlan.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	extensible	InsuranceProductTypeVS http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	PlanContactTypeVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS from this IG
InsurancePlan.contact.name.use	required	NameUse http://hl7.org/fhir/ValueSet/name-use|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.system	required	ContactPointSystem http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1 from the FHIR Standard
InsurancePlan.contact.telecom.use	required	ContactPointUse http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1 from the FHIR Standard
InsurancePlan.coverage:drug-coverage.benefit.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.type	extensible	InsurancePlanType http://terminology.hl7.org/ValueSet/insuranceplan-type|1.0.0
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.category	extensible	PharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.type	extensible	DrugTierVS (a valid code from Codes for medication drug tiers in health plans) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.type	extensible	BenefitCostTypeVS (a valid code from Codes for benefit type of cost) http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiers	required	CopayOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiers	required	CoinsuranceOptionVS http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.value.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard

This structure is derived from InsurancePlan

Summary

Mandatory: 15 elements(2 nested mandatory elements)
Must-Support: 30 elements

Structures

This structure refers to these other structures:

• Insurance Plan Location (http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-InsurancePlanLocation)
• MoneyQuantity (http://hl7.org/fhir/StructureDefinition/MoneyQuantity)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of InsurancePlan.coverage
• The element 1 is sliced based on the value of InsurancePlan.coverage.benefit
• The element 1 is sliced based on the value of InsurancePlan.plan
• The element 1 is sliced based on the value of InsurancePlan.plan.specificCost.benefit.cost