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 |
Generated Narrative: InsurancePlan PayerInsurancePlanA3004t
Last updated: 2021-08-04 18:36:03+0000
Profile: Payer Insurance Plan
identifier: A3004t
status: Active
type: Medicare Advantage
name: Sample Medicare Advantage Plan A3004t
period: 2021-01-01 --> 2021-12-31
coverageArea: Location United States Area
contact
purpose: Patient
telecom: +1 (888) 555-3004
contact
purpose: Plan Marketing Information
name: Sample Medicare Advantage Plan Marketing Website
contact
purpose: Plan Summary Information
name: Sample Medicare Advantage Drug Plan Benefit Website
contact
purpose: Plan Formulary Information
name: Sample Medicare Advantage Drug Plan Formulary Website
coverage
Formulary Reference: InsurancePlan Sample Medicare Advantage Part D Formulary D3004t
type: drug policy
Benefits
Type Drug
plan
type: Drug
specificCost
category: 1 month in network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 10 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 10 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 20 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Generic
cost
type: Copay
qualifiers: No Charge
value: 20 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month in network retail
benefit
type: Zero cost-share preventative
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: No Charge
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Zero cost-share preventative
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: No Charge
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Zero cost-share preventative
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: No Charge
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Zero cost-share preventative
cost
type: Copay
qualifiers: No Charge
value: 0 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: No Charge
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month in network retail
benefit
type: Preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 50 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 50 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 100 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 100 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month in network retail
benefit
type: Non-preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 70 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Non-preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 70 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Non-preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 140 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Non-preferred Brand
cost
type: Copay
qualifiers: No Charge
value: 140 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month in network retail
benefit
type: Specialty
cost
type: Copay
qualifiers: No Charge
value: 100 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 1 month out of network retail
benefit
type: Specialty
cost
type: Copay
qualifiers: No Charge
value: 100 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month in network retail
benefit
type: Specialty
cost
type: Copay
qualifiers: No Charge
value: 200 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
specificCost
category: 3 month out of network retail
benefit
type: Specialty
cost
type: Copay
qualifiers: No Charge
value: 200 $ (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
qualifiers: After Deductible
value: 0 % (Details: UCUM code% = '%')
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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