DaVinci Payer Data Exchange (PDex) US Drug Formulary, published by HL7 Pharmacy Working Group. This is not an authorized publication; it is the continuous build for version 2.0.0). 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
Generated Narrative: Basic
Resource Basic "FormularyItem-D1002-1049640" Updated "2021-08-22 06:36:03+0000"
Profile: Formulary Item
Formulary Reference: InsurancePlan/FormularyD1002 "Sample Medicare Advantage Part D Formulary D1002"
Availability Status: active
Pharmacy Benefit Type: 3 month out of network retail (Codes for pharmacy benefit types#3-month-out-retail)
Drug Tier ID: Brand (Codes for medication drug tiers in health plans#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
value: Count 60 times, Do Once per 30 days
value: 2
value: Count 1 times, Do Once per 180 days
Additional Coverage Information: Prior Authorization required only with a newly started medication Step Therapy required.
code: Formulary Item (Codes for insurance item type#formulary-item)