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 |
{
"resourceType" : "InsurancePlan",
"id" : "PayerInsurancePlanA3004t",
"meta" : {
"lastUpdated" : "2021-08-04T18:36:03.000+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan PayerInsurancePlanA3004t</b></p><a name=\"PayerInsurancePlanA3004t\"> </a><a name=\"hcPayerInsurancePlanA3004t\"> </a><a name=\"PayerInsurancePlanA3004t-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: 2021-08-04 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>: A3004t</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 A3004t</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)555-3004\">+1 (888) 555-3004</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-FormularyD3004t.html\">InsurancePlan Sample Medicare Advantage Part D Formulary D3004t</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 no-charge}\">No Charge</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>: 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 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>: 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>: 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>: 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>: 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>: 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>: 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 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 zero-cost-share-preventative}\">Zero cost-share preventative</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 no-charge}\">No Charge</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 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 zero-cost-share-preventative}\">Zero cost-share preventative</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 no-charge}\">No Charge</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 zero-cost-share-preventative}\">Zero cost-share preventative</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 no-charge}\">No Charge</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 zero-cost-share-preventative}\">Zero cost-share preventative</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 no-charge}\">No Charge</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 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 preferred-brand}\">Preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 50 $<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 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 preferred-brand}\">Preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 50 $<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 preferred-brand}\">Preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<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 preferred-brand}\">Preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 100 $<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 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 non-preferred-brand}\">Non-preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 70 $<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 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 non-preferred-brand}\">Non-preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 70 $<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 non-preferred-brand}\">Non-preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 140 $<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 non-preferred-brand}\">Non-preferred 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 no-charge}\">No Charge</span></p><p><b>value</b>: 140 $<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 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 specialty}\">Specialty</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>: 100 $<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 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 specialty}\">Specialty</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>: 100 $<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 specialty}\">Specialty</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>: 200 $<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 specialty}\">Specialty</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>: 200 $<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>"
},
"identifier" : [
{
"value" : "A3004t"
}
],
"status" : "active",
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS",
"code" : "mediadv"
}
]
}
],
"name" : "Sample Medicare Advantage Plan A3004t",
"period" : {
"start" : "2021-01-01",
"end" : "2021-12-31"
},
"coverageArea" : [
{
🔗 "reference" : "Location/UnitedStatesLocation"
}
],
"contact" : [
{
"purpose" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code" : "PATINF"
}
]
},
"telecom" : [
{
"system" : "phone",
"value" : "+1 (888) 555-3004"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "MARKETING"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Plan Marketing Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "SUMMARY"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Drug Plan Benefit Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
},
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE",
"code" : "FORMULARY"
}
]
},
"name" : {
"text" : "Sample Medicare Advantage Drug Plan Formulary Website"
},
"telecom" : [
{
"system" : "url",
"value" : "http://url/to/health/plan/information"
}
]
}
],
"coverage" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension",
"valueReference" : {
🔗 "reference" : "InsurancePlan/FormularyD3004t"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "DRUGPOL"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
"code" : "drug",
"display" : "Drug"
}
]
}
}
]
}
],
"plan" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
"code" : "drug",
"display" : "Drug"
}
]
},
"specificCost" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "1-month-in-retail",
"display" : "1 month in network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
],
"value" : {
"value" : 10,
"unit" : "$",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "coinsurance",
"display" : "Coinsurance"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "after-deductible",
"display" : "After Deductible"
}
]
}
],
"value" : {
"value" : 0,
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
]
}
]
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE",
"code" : "1-month-out-retail",
"display" : "1 month out of network retail"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE",
"code" : "generic",
"display" : "Generic"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE",
"code" : "copay",
"display" : "Copay"
}
]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE",
"code" : "no-charge",
"display" : "No Charge"
}
]
}
],
"value" : {
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}
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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