PayerInsurancePlanA3002 - TTL Representation - DaVinci Payer Data Exchange (PDex) US Drug Formulary v2.1.0

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
: PayerInsurancePlanA3002

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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/PayerInsurancePlanA3002> a fhir:InsurancePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "PayerInsurancePlanA3002"] ;
  fhir:Resource.meta [
     fhir:Meta.lastUpdated [ fhir:value "2021-05-22T18:36:03.000+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 PayerInsurancePlanA3002</b></p><a name=\"PayerInsurancePlanA3002\"> </a><a name=\"hcPayerInsurancePlanA3002\"> </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: 2021-05-22 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>: A3002</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 A3002</p><p><b>period</b>: 2021-01-01 --&gt; 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)555-3002\">+1 (888) 555-3002</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-FormularyD3002.html\">InsurancePlan Sample Medicare Advantage Part D Formulary D3002</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 before-deductible}\">Before Deductible</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>: 1 %<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>: 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 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>: 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 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>: 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 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 "A3002" ]
  ] ;
  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 A3002"] ;
  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) 555-3002" ]
     ]
  ], [
     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/FormularyD3002> ;
         fhir:Reference.reference [ fhir:value "InsurancePlan/FormularyD3002" ]
       ]
     ] ;
     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 "before-deductible" ] ;
               fhir:Coding.display [ fhir:value "Before Deductible" ]
             ]
           ] ;
           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 "1"^^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 "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 "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 "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 "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 "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 "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 "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 "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/FormularyD3002> a fhir:InsurancePlan .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/InsurancePlan/PayerInsurancePlanA3002.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/InsurancePlan/PayerInsurancePlanA3002.ttl> .