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

: PayerInsurancePlanA1002 - XML Representation

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<InsurancePlan xmlns="http://hl7.org/fhir">
  <id value="PayerInsurancePlanA1002"/>
  <meta>
    <lastUpdated value="2021-08-22T18:36:03.000+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: InsurancePlan PayerInsurancePlanA1002</b></p><a name="PayerInsurancePlanA1002"> </a><a name="hcPayerInsurancePlanA1002"> </a><a name="PayerInsurancePlanA1002-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-PayerInsurancePlan.html">Payer Insurance Plan</a></p></div><p><b>identifier</b>: A1002</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 A1002</p><p><b>period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>coverageArea</b>: <a href="Location-StateOfCTLocation.html">Location State of CT 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)555-1002">+1 (888) 555-1002</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}">Plan Marketing Information</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}">Plan Summary Information</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}">Plan Formulary Information</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-FormularyD1002.html">InsurancePlan Sample Medicare Advantage Part D Formulary D1002</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 brand}">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 after-deductible}">After Deductible</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>: 20 %<span style="background: LightGoldenRodYellow"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote></blockquote></div>
  </text>
  <identifier>
    <value value="A1002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system
              value="http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS"/>
      <code value="mediadv"/>
    </coding>
  </type>
  <name value="Sample Medicare Advantage Plan A1002"/>
  <period>
    <start value="2021-01-01"/>
    <end value="2021-12-31"/>
  </period>
  <coverageArea>🔗 
    <reference value="Location/StateOfCTLocation"/>
  </coverageArea>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/contactentity-type"/>
        <code value="PATINF"/>
      </coding>
    </purpose>
    <telecom>
      <system value="phone"/>
      <value value="+1 (888) 555-1002"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="MARKETING"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Plan Marketing Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="SUMMARY"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Drug Plan Benefit Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE"/>
        <code value="FORMULARY"/>
      </coding>
    </purpose>
    <name>
      <text value="Sample Medicare Advantage Drug Plan Formulary Website"/>
    </name>
    <telecom>
      <system value="url"/>
      <value value="http://url/to/health/plan/information"/>
    </telecom>
  </contact>
  <coverage>
    <extension
               url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension">
      <valueReference>🔗 
        <reference value="InsurancePlan/FormularyD1002"/>
      </valueReference>
    </extension>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
        <code value="DRUGPOL"/>
      </coding>
    </type>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/insurance-plan-type"/>
          <code value="drug"/>
          <display value="Drug"/>
        </coding>
      </type>
    </benefit>
  </coverage>
  <plan>
    <type>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/insurance-plan-type"/>
        <code value="drug"/>
        <display value="Drug"/>
      </coding>
    </type>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
          <code value="1-month-in-retail"/>
          <display value="1 month in network retail"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"/>
            <code value="brand"/>
            <display value="Brand"/>
          </coding>
        </type>
        <cost>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
              <code value="copay"/>
              <display value="Copay"/>
            </coding>
          </type>
          <qualifiers>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
              <code value="after-deductible"/>
              <display value="After Deductible"/>
            </coding>
          </qualifiers>
          <value>
            <value value="20"/>
            <unit value="$"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
              <code value="coinsurance"/>
              <display value="Coinsurance"/>
            </coding>
          </type>
          <qualifiers>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
              <code value="after-deductible"/>
              <display value="After Deductible"/>
            </coding>
          </qualifiers>
          <value>
            <value value="20"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
  </plan>
</InsurancePlan>