DaVinci Payer Data Exchange (PDex) US Drug Formulary | STU2 Ballot
1.2.0 - STU 2 Ballot United States of America flag

DaVinci Payer Data Exchange (PDex) US Drug Formulary | STU2 Ballot, published by HL7 Pharmacy Working Group. This is not an authorized publication; it is the continuous build for version 1.2.0). 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

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

US Drug Formulary Server Capability Statement

This Section describes the expected capabilities of the US Drug Formulary Server actor which is responsible for providing responses to the queries submitted by the US Drug Formulary Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Drug Formulary Server are defined.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

Basic-code

Accesses the Code of a Basis resource to find a FormularyItem

Basic-drug-tier

Accesses the Drug Tier of a FormularyItem

Basic-formulary

Accesses the formulary reference of a FormularyItem

Basic-lastupdated

Accesses the last updated date of a FormularyItem

Basic-period

Accesses the active period of a FormularyItem

Basic-pharmacy-benefit-type

Accesses the Pharmacy Benefit Type of a FormularyItem

Basic-status

Accesses the status of a FormularyItem

Basic-subject

Accesses the subject FormularyDrug (MedicationKnowledge) reference of a FormularyItem

InsurancePlan-coverage-area

Search InsurancePlan by coverage location.

InsurancePlan-coverage-type

Accesses the coverage type of an InsurancePlan

InsurancePlan-formulary-coverage

Accesses the Coverage Formulary Reference of an InsurancePlan

InsurancePlan-identifier

Accesses the business identifier of an InsurancePlan

InsurancePlan-lastupdated

Accesses the last updated date of an InsurancePlan

InsurancePlan-name

Accesses the name of an InsurancePlan

InsurancePlan-period

Accesses the active period of an InsurancePlan

InsurancePlan-status

Accesses the status of an InsurancePlan

InsurancePlan-type

Accesses the Type of an InsurancePlan

MedicationKnowledge-code

Accesses the status of a FormularyDrug

MedicationKnowledge-doseform

Accesses the dose form of a FormularyDrug

MedicationKnowledge-drug-name

Accesses the Drug Name of a FormularyDrug

MedicationKnowledge-lastupdated

Accesses the last updated date of a FormularyItem

MedicationKnowledge-status

Accesses the status of a FormularyDrug

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

Formulary

The Formulary provides general information about a formulary and acts as an organizing construct that associated FormularyItem resources point to. The Formulary combined with its associated FormularyItem and FormularyDrug resources represent a formulary list that includes the set of drugs covered and the requirements and limitations of the coverage.

Formulary Drug

Drug information which may be part of a formulary including its RxNorm code and dose form.

Formulary Item

A resource that describes a drug’s relationship to a drug plan, including drug tier, prior authorization requirements, and more. The set of FormularyItem resources associated with a particular drug plan represents the drug plans formulary.

Insurance Plan Location

A Location describing a geographic region or are where the insurance plan coverage is available.

Payer Insurance Plan

The Payer InsurancePlan that defines the health insurance product, which include coverage benefits that are offered, and additional information about the offering, such as a coverage area, contact information, brochure locations, etc. The health insurance product offers one or more types of coverage, each of which may define a plan of covered benefits with the particular cost sharing structure offered to a consumer. Health insurance plans that include drug coverage reference a formulary that provides details about drugs that are covered under the plan including requirements and limitations of the coverage specific to each drug.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

Availability Period

The period for which this item is available on the formulary. Drugs may appear on a formulary, but not considered “active” for the current year.

Availability Status

A boolean indicating whether the formulary item is currently available under the formulary. Drugs may appear on a formulary, but not considered “active” for the current year. Drugs may also be removed during the course of a plan year.

Drug Tier ID

A code that describes the coverage status of a drug in a health plan (e.g., preferred generic, specialty, etc.)

Formulary Reference

Reference to the formulary this item belongs to.

Pharmacy Benefit Type

A CodeableConcept indicating the pharmacy benefit type the formulary drug is available through the associated plan. This pharmacy benefit type is specific to the FormularyDrug and indicates which of the pharmacy benefit type from the plan applies to the particular formulary drug.

Prior Authorization

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug.

Prior Authorization New Starts Only

A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug for new starts only. (Only include if PriorAuthorization = true)

Quantity Limit

A Boolean indication of whether the coverage plan imposes a quantity limit on this drug.

Quantity Limit Detail

A detailed definition of the quantity limits the coverage plan imposes on this drug. These limit details may include (potentially including a rolling dispense limit, maximum daily, or therapy days for a period of time. (Only include if QuantityLimit = true)

Step Therapy Limit

A boolean indicating whether the coverage plan imposes a step therapy requirement on this drug meaning another drug may need to be tried beforehand.

Step Therapy Limit New Starts Only

A boolean indicating whether the coverage plan imposes a step therapy requirement on this drug meaning another drug may need to be tried beforehand for new starts only (Not required if patient has previously met step therapy requirements). (Only include if StepTherapyLimit = true)

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

Benefit type of cost

Benefit type of cost

Qualifier for coinsurance rate

Qualifier for coinsurance rate

Qualifier of copay amount

Qualifier of copay amount

Drug tier of medication in health plan

The drug tier of a particular medication in a health plan. The base set are examples. Each plan may have its own controlled vocabulary.

Insurance item type

Types of insurance items

Pharmacy benefit types

Pharmacy benefit types. Each payer will have its own controlled vocabulary.

Type of plan contact

Type of plan contact

Type of plan

Types of plans

Semantic Drug Form Group Codes

Semantic Drug Form Group codes with Term Types (TTY) of Semantic Clinical Drug Form (SCDG) and Semantic Branded Drug Form Group (SBDG)

Semantic Drug Codes

Semantic Drug codes with Term Types (TTY) of Semantic Clinical Drug (SCD), Semantic Branded Drug (SBD), Generic Pack (GPCK), or Branded Pack (BPCK)

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

Codes for benefit type of cost

Types of out of pockets costs associated with the benefit

Code for qualifier for coinsurance rate codes

Code for qualifier for coinsurance rate

Codes for qualifier of copay amount

Codes for qualifier of copay amount

Codes for medication drug tiers in health plans

Codes to represent the drug tier of a particular medication in a health plan. Base set are examples. Each plan may have its own controlled vocabulary.

Codes for insurance item type

Types of insurance items

Codes for pharmacy benefit types

Codes for pharmacy benefit types. Each payer will have its own controlled vocabulary.

Codes for type of plan contact

Type of plan contact

Codes for type of plan

Types of plans

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

FormularyD1002

Formulary D1002

FormularyD3001

Formulary D3001

FormularyD3002

Formulary D3002

FormularyD3004t

Formulary D3004t

FormularyDrug-1000091

Formulary Drug 1000091

FormularyDrug-1049640

Formulary Drug 1049640

FormularyDrug-1541228

Formulary Drug 1541228

FormularyDrug-209459

Formulary Drug 209459

FormularyDrug-284520

Formulary Drug 284520

FormularyItem-D1002-1000091

Formulary Item for Formulary D1002 Drug 1000091

FormularyItem-D1002-1049640

Formulary Item for Formulary D1002 Drug 1049640

FormularyItem-D1002-209459

Formulary Item for Formulary D1002 Drug 209459

FormularyItem-D1002-284520

Formulary Item for Formulary D1002 Drug 284520

FormularyItem-D3001-1000091

Formulary Item for Insurance Formulary D3001 Drug 1000091

FormularyItem-D3002-1000091

Formulary Item for Insurance Formulary D3002 Drug 1000091

FormularyItem-D3004t-1049640

Formulary Item for Insurance Formulary D3004t Drug 1049640

PayerInsurancePlanA1002

Payer Insurance Plan A1002

PayerInsurancePlanA3001

Payer Insurance Plan A3001

PayerInsurancePlanA3002

Payer Insurance Plan A3002

PayerInsurancePlanA3004t

Payer Insurance Plan A3004t

StateOfCTLocation

State of CT Area

UnitedStatesLocation

United States Area