DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU 3 (ci-build) 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

: FormularyItem-D1002-1049640 - TTL Representation

Page standards status: Informative

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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 -------------------------------------------------------------------

 a fhir:Basic ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "FormularyItem-D1002-1049640"] ; # 
  fhir:meta [
fhir:lastUpdated [ fhir:v "2021-08-22T18:36:03.000+00:00"^^xsd:dateTime ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyItem>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Basic FormularyItem-D1002-1049640</b></p><a name=\"FormularyItem-D1002-1049640\"> </a><a name=\"hcFormularyItem-D1002-1049640\"> </a><a name=\"FormularyItem-D1002-1049640-en-US\"> </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: 2021-08-22 18:36:03+0000</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-usdf-FormularyItem.html\">Formulary Item</a></p></div><p><b>Formulary Reference</b>: <a href=\"InsurancePlan-FormularyD1002.html\">InsurancePlan Sample Medicare Advantage Part D Formulary D1002</a></p><p><b>Availability Status</b>: active</p><p><b>Pharmacy Benefit Type</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><p><b>Drug Tier ID</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE brand}\">Brand</span></p><p><b>Availability Period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>Prior Authorization</b>: true</p><p><b>Prior Authorization New Starts Only</b>: true</p><p><b>Step Therapy Limit</b>: true</p><p><b>Step Therapy Limit New Starts Only</b>: false</p><p><b>Quantity Limit</b>: true</p><blockquote><p><b>Quantity Limit Detail</b></p><ul><li>Rolling: Count 60  times, Once per30 days</li><li>MaximumDaily: 2</li><li>DaysSupply: Count 1  times, Once per180 days</li></ul></blockquote><p><b>Additional Coverage Information</b>: </p><div><p>Prior Authorization required only with a newly started medication\nStep Therapy required.</p>\n</div><p><b>code</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS formulary-item}\">Formulary Item</span></p><p><b>subject</b>: <a href=\"MedicationKnowledge-FormularyDrug-1049640.html\">MedicationKnowledge acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]</a></p></div>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "InsurancePlan/FormularyD1002" ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityStatus-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "active" ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PharmacyBenefitType-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "3-month-out-retail" ] ;
fhir:display [ fhir:v "3 month out of network retail" ]       ] )     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierID-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"^^xsd:anyURI ] ;
fhir:code [ fhir:v "brand" ] ;
fhir:display [ fhir:v "Brand" ]       ] )     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AvailabilityPeriod-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Period ;
fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-12-31"^^xsd:date ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorization-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PriorAuthorizationNewStartsOnly-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimit-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-StepTherapyLimitNewStartsOnly-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimit-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "Rolling"^^xsd:anyURI ] ;
fhir:value [
a fhir:Timing ;
fhir:repeat [
fhir:count [ fhir:v "60"^^xsd:positiveInteger ] ;
fhir:period [ fhir:v "30"^^xsd:decimal ] ;
fhir:periodUnit [ fhir:v "d" ]         ]       ]     ] [
fhir:url [ fhir:v "MaximumDaily"^^xsd:anyURI ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "2"^^xsd:decimal ]       ]     ] [
fhir:url [ fhir:v "DaysSupply"^^xsd:anyURI ] ;
fhir:value [
a fhir:Timing ;
fhir:repeat [
fhir:bounds [
a fhir:Duration ;
fhir:value [ fhir:v "365"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "d" ]           ] ;
fhir:count [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:period [ fhir:v "180"^^xsd:decimal ] ;
fhir:periodUnit [ fhir:v "d" ]         ]       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-QuantityLimitDetail-extension"^^xsd:anyURI ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-AdditionalCoverageInformation-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Prior Authorization required only with a newly started medication\nStep Therapy required." ]
  ] ) ; # 
  fhir:code [
    ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-InsuranceItemTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "formulary-item" ] ;
fhir:display [ fhir:v "Formulary Item" ]     ] )
  ] ; # 
  fhir:subject [
fhir:reference [ fhir:v "MedicationKnowledge/FormularyDrug-1049640" ]
  ] . #