PayerInsurancePlanA3004t
type: InsurancePlan
node role: treeRoot
id:
  v: PayerInsurancePlanA3004t
meta:
  last updated:
    v: 2021-08-04T18:36:03.000+00:00
  profile:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan
    link: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan
text:
  status:
    v: extensions
  div: 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: Marketting name: Sample Medicare Advantage Plan Marketing Website telecom: http://url/to/health/plan/information contact purpose: Summary name: Sample Medicare Advantage Drug Plan Benefit Website telecom: http://url/to/health/plan/information contact purpose: Formulary name: Sample Medicare Advantage Drug Plan Formulary Website telecom: http://url/to/health/plan/information 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 mo…
identifier:
  value:
    v: A3004t
status:
  v: active
type:
  coding:
    system:
      v: http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS
    code:
      v: mediadv
name:
  v: Sample Medicare Advantage Plan A3004t
period:
  start:
    v: 2021-01-01
  end:
    v: 2021-12-31
coverage area:
  link: http://hl7.org/fhir/us/davinci-drug-formulary/Location/UnitedStatesLocation
  reference:
    v: Location/UnitedStatesLocation
contact:
  purpose:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/contactentity-type
      code:
        v: PATINF
  telecom:
    system:
      v: phone
    value:
      v: +1 (888) 555-3004
contact:
  purpose:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE
      code:
        v: MARKETING
  name:
    text:
      v: Sample Medicare Advantage Plan Marketing Website
  telecom:
    system:
      v: url
    value:
      v: http://url/to/health/plan/information
contact:
  purpose:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE
      code:
        v: SUMMARY
  name:
    text:
      v: Sample Medicare Advantage Drug Plan Benefit Website
  telecom:
    system:
      v: url
    value:
      v: http://url/to/health/plan/information
contact:
  purpose:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PlanContactTypeCS-TEMPORARY-TRIAL-USE
      code:
        v: FORMULARY
  name:
    text:
      v: Sample Medicare Advantage Drug Plan Formulary Website
  telecom:
    system:
      v: url
    value:
      v: http://url/to/health/plan/information
coverage:
  extension:
    url:
      v: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
    value: Reference
      link: http://hl7.org/fhir/us/davinci-drug-formulary/InsurancePlan/FormularyD3004t
      reference:
        v: InsurancePlan/FormularyD3004t
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v3-ActCode
      code:
        v: DRUGPOL
plan:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/insurance-plan-type
      code:
        v: drug
      display:
        v: Drug

v: drug

v: Drug

v: 1-month-in-retail

v: 1 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: generic
display:
  v: Generic

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 10
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-out-retail

v: 1 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: generic
display:
  v: Generic

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 10
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-in-retail

v: 3 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: generic
display:
  v: Generic

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 20
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-out-retail

v: 3 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: generic
display:
  v: Generic

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 20
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-in-retail

v: 1 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: zero-cost-share-preventative
display:
  v: Zero cost-share preventative

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-out-retail

v: 1 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: zero-cost-share-preventative
display:
  v: Zero cost-share preventative

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-in-retail

v: 3 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: zero-cost-share-preventative
display:
  v: Zero cost-share preventative

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-out-retail

v: 3 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: zero-cost-share-preventative
display:
  v: Zero cost-share preventative

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-in-retail

v: 1 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: preferred-brand
display:
  v: Preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 50
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-out-retail

v: 1 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: preferred-brand
display:
  v: Preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 50
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-in-retail

v: 3 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: preferred-brand
display:
  v: Preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 100
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-out-retail

v: 3 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: preferred-brand
display:
  v: Preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 100
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-in-retail

v: 1 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: non-preferred-brand
display:
  v: Non-preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 70
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-out-retail

v: 1 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: non-preferred-brand
display:
  v: Non-preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 70
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-in-retail

v: 3 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: non-preferred-brand
display:
  v: Non-preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 140
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-out-retail

v: 3 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: non-preferred-brand
display:
  v: Non-preferred Brand

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 140
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-in-retail

v: 1 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: specialty
display:
  v: Specialty

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 100
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 1-month-out-retail

v: 1 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: specialty
display:
  v: Specialty

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 100
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-in-retail

v: 3 month in network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: specialty
display:
  v: Specialty

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 200
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %

v: 3-month-out-retail

v: 3 month out of network retail

system:
  v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE
code:
  v: specialty
display:
  v: Specialty

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: copay
  display:
    v: Copay

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: no-charge
  display:
    v: No Charge

value:
  v: 200
unit:
  v: $
system:
  v: urn:iso:std:iso:4217
code:
  v: USD

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
  code:
    v: coinsurance
  display:
    v: Coinsurance

coding:
  system:
    v: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
  code:
    v: after-deductible
  display:
    v: After Deductible

value:
  v: 0
system:
  v: http://unitsofmeasure.org
code:
  v: %