DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1 United States of America flag

DaVinci Payer Data Exchange (PDex) US Drug Formulary, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pdex-formulary/ and changes regularly. See the Directory of published versions

Example Basic: FormularyItem-D1002-1049640

Page standards status: Informative

Generated Narrative: Basic FormularyItem-D1002-1049640

Last updated: 2021-08-22 18:36:03+0000

Profile: Formulary Item

Formulary Reference: InsurancePlan Sample Medicare Advantage Part D Formulary D1002

Availability Status: active

Pharmacy Benefit Type: 3 month out of network retail

Drug Tier ID: Brand

Availability Period: 2021-01-01 --> 2021-12-31

Prior Authorization: true

Prior Authorization New Starts Only: true

Step Therapy Limit: true

Step Therapy Limit New Starts Only: false

Quantity Limit: true

Quantity Limit Detail

  • Rolling: Count 60 times, Once per 30 days
  • MaximumDaily: 2
  • DaysSupply: Count 1 times, Once per 180 days

Additional Coverage Information:

Prior Authorization required only with a newly started medication Step Therapy required.

code: Formulary Item

subject: MedicationKnowledge acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]