DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU 3 (ci-build)
DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU 3 (ci-build)
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
| Page standards status: Informative |
<InsurancePlan xmlns="http://hl7.org/fhir">
<id value="PayerInsurancePlanA3002"/>
<meta>
<lastUpdated value="2021-05-22T18:36:03.000+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 PayerInsurancePlanA3002</b></p><a name="PayerInsurancePlanA3002"> </a><a name="hcPayerInsurancePlanA3002"> </a><a name="PayerInsurancePlanA3002-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: 2021-05-22 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 --> 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}">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-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>
</text>
<identifier>
<value value="A3002"/>
</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 A3002"/>
<period>
<start value="2021-01-01"/>
<end value="2021-12-31"/>
</period>
<coverageArea>🔗
<reference value="Location/UnitedStatesLocation"/>
</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) 555-3002"/>
</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/FormularyD3002"/>
</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="generic"/>
<display value="Generic"/>
</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="before-deductible"/>
<display value="Before Deductible"/>
</coding>
</qualifiers>
<value>
<value value="10"/>
<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="1"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
<code value="1-month-out-retail"/>
<display value="1 month out of 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="generic"/>
<display value="Generic"/>
</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="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
<code value="after-deductible"/>
<display value="After Deductible"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
<code value="3-month-in-retail"/>
<display value="3 month in network retail"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE"/>
<code value="generic"/>
<display value="Generic"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</type>
<qualifiers>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE"/>
<code value="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="$"/>
<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="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE"/>
<code value="3-month-out-retail"/>
<display value="3 month out of 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="generic"/>
<display value="Generic"/>
</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="no-charge"/>
<display value="No Charge"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<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="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
</plan>
</InsurancePlan>
IG © 2022+ HL7 International / Pharmacy. Package hl7.fhir.us.davinci-drug-formulary#2.1.0 based on FHIR 4.0.1. Generated 2024-09-24
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