DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1
DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1
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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@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/InsurancePlan/PayerInsurancePlanA3004t> a fhir:InsurancePlan ; fhir:nodeRole fhir:treeRoot ; fhir:Resource.id [ fhir:value "PayerInsurancePlanA3004t"] ; fhir:Resource.meta [ fhir:Meta.lastUpdated [ fhir:value "2021-08-04T18:36:03.000+00:00"^^xsd:dateTime ] ; fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan PayerInsurancePlanA3004t</b></p><a name=\"PayerInsurancePlanA3004t\"> </a><a name=\"hcPayerInsurancePlanA3004t\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2021-08-04 18:36:03+0000</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-PayerInsurancePlan.html\">Payer Insurance Plan</a></p></div><p><b>identifier</b>: A3004t</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS mediadv}\">Medicare Advantage</span></p><p><b>name</b>: Sample Medicare Advantage Plan A3004t</p><p><b>period</b>: 2021-01-01 --> 2021-12-31</p><p><b>coverageArea</b>: <a href=\"Location-UnitedStatesLocation.html\">Location United States Area</a></p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/contactentity-type PATINF}\">Patient</span></p><p><b>telecom</b>: <a href=\"tel:+1(888)555-3004\">+1 (888) 555-3004</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE MARKETING}\">Marketting</span></p><p><b>name</b>: Sample Medicare Advantage Plan Marketing Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE SUMMARY}\">Summary</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Benefit Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE FORMULARY}\">Formulary</span></p><p><b>name</b>: Sample Medicare Advantage Drug Plan Formulary Website</p><p><b>telecom</b>: <a href=\"http://url/to/health/plan/information\">http://url/to/health/plan/information</a></p></blockquote><blockquote><p><b>coverage</b></p><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD3004t.html\">InsurancePlan Sample Medicare Advantage Part D Formulary D3004t</a></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode DRUGPOL}\">drug policy</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insurance-plan-type drug}\">Drug</span></td></tr></table></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insurance-plan-type drug}\">Drug</span></p><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-in-retail}\">1 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE generic}\">Generic</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 10 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-out-retail}\">1 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE generic}\">Generic</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 10 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-in-retail}\">3 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE generic}\">Generic</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 20 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE generic}\">Generic</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 20 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-in-retail}\">1 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE zero-cost-share-preventative}\">Zero cost-share preventative</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-out-retail}\">1 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE zero-cost-share-preventative}\">Zero cost-share preventative</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-in-retail}\">3 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE zero-cost-share-preventative}\">Zero cost-share preventative</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE zero-cost-share-preventative}\">Zero cost-share preventative</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-in-retail}\">1 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE preferred-brand}\">Preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 50 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-out-retail}\">1 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE preferred-brand}\">Preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 50 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-in-retail}\">3 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE preferred-brand}\">Preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE preferred-brand}\">Preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-in-retail}\">1 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE non-preferred-brand}\">Non-preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 70 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-out-retail}\">1 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE non-preferred-brand}\">Non-preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 70 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-in-retail}\">3 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE non-preferred-brand}\">Non-preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 140 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE non-preferred-brand}\">Non-preferred Brand</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 140 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-in-retail}\">1 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE specialty}\">Specialty</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 1-month-out-retail}\">1 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE specialty}\">Specialty</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-in-retail}\">3 month in network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE specialty}\">Specialty</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 200 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE 3-month-out-retail}\">3 month out of network retail</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE specialty}\">Specialty</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE copay}\">Copay</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE no-charge}\">No Charge</span></p><p><b>value</b>: 200 $<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE coinsurance}\">Coinsurance</span></p><p><b>qualifiers</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE after-deductible}\">After Deductible</span></p><p><b>value</b>: 0 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>" ] ; fhir:InsurancePlan.identifier [ fhir:index -1 ; fhir:Identifier.value [ fhir:value "A3004t" ] ] ; fhir:InsurancePlan.status [ fhir:value "active"] ; fhir:InsurancePlan.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS" ] ; fhir:Coding.code [ fhir:value "mediadv" ] ] ] ; fhir:InsurancePlan.name [ fhir:value "Sample Medicare Advantage Plan A3004t"] ; fhir:InsurancePlan.period [ fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2021-12-31"^^xsd:date ] ] ; fhir:InsurancePlan.coverageArea [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Location/UnitedStatesLocation> ; fhir:Reference.reference [ fhir:value "Location/UnitedStatesLocation" ] ] ; fhir:InsurancePlan.contact [ fhir:index -1 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/contactentity-type" ] ; fhir:Coding.code [ fhir:value "PATINF" ] ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "+1 (888) 555-3004" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "MARKETING" ] ] ] ; fhir:InsurancePlan.contact.name [ fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Plan Marketing Website" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "SUMMARY" ] ] ] ; fhir:InsurancePlan.contact.name [ fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Drug Plan Benefit Website" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "FORMULARY" ] ] ] ; fhir:InsurancePlan.contact.name [ fhir:HumanName.text [ fhir:value "Sample Medicare Advantage Drug Plan Formulary Website" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "http://url/to/health/plan/information" ] ] ] ; fhir:InsurancePlan.coverage [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension" ] ; fhir:Extension.valueReference [ fhir:link <http://hl7.org/fhir/InsurancePlan/FormularyD3004t> ; fhir:Reference.reference [ fhir:value "InsurancePlan/FormularyD3004t" ] ] ] ; fhir:InsurancePlan.coverage.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ] ; fhir:Coding.code [ fhir:value "DRUGPOL" ] ] ] ; fhir:InsurancePlan.coverage.benefit [ fhir:index -1 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insurance-plan-type" ] ; fhir:Coding.code [ fhir:value "drug" ] ; fhir:Coding.display [ fhir:value "Drug" ] ] ] ] ] ; fhir:InsurancePlan.plan [ fhir:index -1 ; fhir:InsurancePlan.plan.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insurance-plan-type" ] ; fhir:Coding.code [ fhir:value "drug" ] ; fhir:Coding.display [ fhir:value "Drug" ] ] ] ; fhir:InsurancePlan.plan.specificCost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-in-retail" ] ; fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "generic" ] ; fhir:Coding.display [ fhir:value "Generic" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-out-retail" ] ; fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "generic" ] ; fhir:Coding.display [ fhir:value "Generic" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-in-retail" ] ; fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ] ; 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"http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-out-retail" ] ; fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; 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fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-in-retail" ] ; fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ] ; fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-out-retail" ] ; fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ] ; fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-in-retail" ] ; fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ] ; fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-out-retail" ] ; fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "zero-cost-share-preventative" ] ; fhir:Coding.display [ fhir:value "Zero cost-share preventative" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ 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"http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-in-retail" ] ; fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "preferred-brand" ] ; fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-out-retail" ] ; fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "preferred-brand" ] ; fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-in-retail" ] ; fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "preferred-brand" ] ; fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-out-retail" ] ; fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "preferred-brand" ] ; fhir:Coding.display [ fhir:value "Preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-in-retail" ] ; fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "non-preferred-brand" ] ; fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-out-retail" ] ; fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "non-preferred-brand" ] ; fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-in-retail" ] ; fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "non-preferred-brand" ] ; fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "140"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-out-retail" ] ; fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "non-preferred-brand" ] ; fhir:Coding.display [ fhir:value "Non-preferred Brand" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "140"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-in-retail" ] ; fhir:Coding.display [ fhir:value "1 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "specialty" ] ; fhir:Coding.display [ fhir:value "Specialty" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "1-month-out-retail" ] ; fhir:Coding.display [ fhir:value "1 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "specialty" ] ; fhir:Coding.display [ fhir:value "Specialty" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-in-retail" ] ; fhir:Coding.display [ fhir:value "3 month in network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "specialty" ] ; fhir:Coding.display [ fhir:value "Specialty" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "3-month-out-retail" ] ; fhir:Coding.display [ fhir:value "3 month out of network retail" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "specialty" ] ; fhir:Coding.display [ fhir:value "Specialty" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copay" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "no-charge" ] ; fhir:Coding.display [ fhir:value "No Charge" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "$" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "coinsurance" ] ; fhir:Coding.display [ fhir:value "Coinsurance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After Deductible" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ] ] . <http://hl7.org/fhir/Location/UnitedStatesLocation> a fhir:Location . <http://hl7.org/fhir/InsurancePlan/FormularyD3004t> a fhir:InsurancePlan . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/InsurancePlan/PayerInsurancePlanA3004t.ttl> a owl:Ontology ; owl:imports fhir:fhir.ttl ; owl:versionIRI <http://build.fhir.org/InsurancePlan/PayerInsurancePlanA3004t.ttl> .
IG © 2025+ HL7 International / Pharmacy.
Package hl7.fhir.us.davinci-drug-formulary#2.1.0 based on FHIR 4.0.1.
Generated
2026-08-03
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