DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1 United States of America flag

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

Resource Profile: Payer Insurance Plan

Official URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan Version: 2.1.0
Standards status: Trial-use Computable Name: PayerInsurancePlan
Other Identifiers: OID:2.25.74595174031514506193398850787025340071.42.12

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.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
... meta Σ 0..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... lastUpdated SΣ 1..1 instant When the resource version last changed
ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Product type
Binding: Insurance Product Type VS (extensible)
ele-1: All FHIR elements must have a @value or children
... name SΣC 0..1 string Official name
ele-1: All FHIR elements must have a @value or children
... period S 0..1 Period When the product is available
ele-1: All FHIR elements must have a @value or children
... coverageArea SΣ 0..* Reference(Insurance Plan Location) Where product applies
ele-1: All FHIR elements must have a @value or children
... contact 0..* BackboneElement Contact information for the Insurance Plan including URLs for brochure and formulary information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... purpose 0..1 CodeableConcept The type of contact
Binding: Type of plan contact (extensible)
ele-1: All FHIR elements must have a @value or children
.... name S 0..1 HumanName A name associated with the contact
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.


ele-1: All FHIR elements must have a @value or children
..... text SΣ 0..1 string Text representation of the full name
ele-1: All FHIR elements must have a @value or children
.... telecom S 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
ele-1: All FHIR elements must have a @value or children
..... system SΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.


ele-1: All FHIR elements must have a @value or children
..... value SΣ 0..1 string The actual contact point details
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code home | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.


ele-1: All FHIR elements must have a @value or children
... Slices for coverage S 1..* BackboneElement Coverage details
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... coverage:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type S 1..1 CodeableConcept Type of coverage
ele-1: All FHIR elements must have a @value or children
..... benefit 1..* BackboneElement List of benefits
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... type 1..1 CodeableConcept Type of benefit
ele-1: All FHIR elements must have a @value or children
.... coverage:drug-coverage S 1..* BackboneElement Coverage details
ele-1: All FHIR elements must have a @value or children
..... Slices for extension S 1..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... usdf-FormularyReference-extension S 1..* Reference(Formulary) Formulary Reference
URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyReference-extension
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type S 1..1 CodeableConcept Type of coverage
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DRUGPOL
..... Slices for benefit 1..* BackboneElement List of benefits
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
...... benefit:All Slices Content/Rules for all slices
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
....... type 1..1 CodeableConcept Type of benefit
Binding: Insurance plan type (extensible)
ele-1: All FHIR elements must have a @value or children
...... benefit:drug-plan S 1..* BackboneElement List of benefits
ele-1: All FHIR elements must have a @value or children
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
....... type 1..1 CodeableConcept Type of benefit
Binding: Insurance plan type (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
........ coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
......... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
......... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drug
......... display 1..1 string Representation defined by the system
Fixed Value: Drug
... Slices for plan S 1..* BackboneElement Plan details
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... plan:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type 0..1 CodeableConcept Type of plan
Binding: Insurance plan type (extensible)
ele-1: All FHIR elements must have a @value or children
.... plan:drug-plan S 1..* BackboneElement Drug plan
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... identifier SΣ 0..* Identifier Business Identifier for Product
ele-1: All FHIR elements must have a @value or children
..... type 1..1 CodeableConcept Type of plan
Binding: Insurance plan type (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drug
....... display 1..1 string Representation defined by the system
Fixed Value: Drug
..... network 0..* Reference(Organization) Pharmacy benefit types that are part of the drug plan
ele-1: All FHIR elements must have a @value or children
..... specificCost S 1..* BackboneElement Pharmacy benefit type specific cost
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Pharmacy Benefit Type
Binding: Pharmacy benefit types (extensible)
ele-1: All FHIR elements must have a @value or children
...... benefit S 1..* BackboneElement Drug tier benefit
ele-1: All FHIR elements must have a @value or children
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
....... type S 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)
ele-1: All FHIR elements must have a @value or children
....... Slices for cost S 1..* BackboneElement List of the costs
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
........ cost:All Slices Content/Rules for all slices
......... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
......... type 1..1 CodeableConcept Type of cost
Binding: Benefit type of cost (extensible)
ele-1: All FHIR elements must have a @value or children
......... qualifiers S 1..1 CodeableConcept Additional information about the cost
ele-1: All FHIR elements must have a @value or children
......... value S 0..1 Quantity The actual cost value
ele-1: All FHIR elements must have a @value or children
........ cost:copay S 0..1 BackboneElement Copay costs
ele-1: All FHIR elements must have a @value or children
......... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
......... type 1..1 CodeableConcept Type of cost
Binding: Benefit type of cost (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
.......... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
........... code 1..1 code Symbol in syntax defined by the system
Fixed Value: copay
......... qualifiers S 1..1 CodeableConcept Additional information about the cost
Binding: Qualifier of copay amount (required)
ele-1: All FHIR elements must have a @value or children
......... value S 1..1 MoneyQuantity The actual cost value
ele-1: All FHIR elements must have a @value or children
.......... value SΣ 1..1 decimal Numerical value (with implicit precision)
ele-1: All FHIR elements must have a @value or children
.......... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.


ele-1: All FHIR elements must have a @value or children
.......... system ΣC 0..1 uri System that defines coded unit form
ele-1: All FHIR elements must have a @value or children
Required Pattern: urn:iso:std:iso:4217
.......... code Σ 0..1 code Coded form of the unit
ele-1: All FHIR elements must have a @value or children
Required Pattern: USD
........ cost:coinsurance S 0..1 BackboneElement Coinsurance costs
ele-1: All FHIR elements must have a @value or children
......... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
......... type 1..1 CodeableConcept Type of cost
Binding: Benefit type of cost (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
.......... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE
........... code 1..1 code Symbol in syntax defined by the system
Fixed Value: coinsurance
......... qualifiers S 1..1 CodeableConcept Additional information about the cost
Binding: Qualifier for coinsurance rate (required)
ele-1: All FHIR elements must have a @value or children
......... value S 1..1 Quantity The actual cost value
ele-1: All FHIR elements must have a @value or children
.......... value SΣ 1..1 decimal Numerical value (with implicit precision)
ele-1: All FHIR elements must have a @value or children
.......... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.


ele-1: All FHIR elements must have a @value or children
.......... system ΣC 0..1 uri System that defines coded unit form
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://unitsofmeasure.org
.......... code Σ 0..1 code Coded form of the unit
ele-1: All FHIR elements must have a @value or children
Required Pattern: %

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
InsurancePlan.statusrequiredPublicationStatus
http://hl7.org/fhir/ValueSet/publication-status|4.0.1
from the FHIR Standard
InsurancePlan.typeextensibleInsuranceProductTypeVS
http://hl7.org/fhir/us/davinci-pdex-plan-net/ValueSet/InsuranceProductTypeVS
InsurancePlan.contact.purposeextensiblePlanContactTypeVS
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PlanContactTypeVS
from this IG
InsurancePlan.contact.name.userequiredNameUse
http://hl7.org/fhir/ValueSet/name-use|4.0.1
from the FHIR Standard
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1
from the FHIR Standard
InsurancePlan.contact.telecom.userequiredContactPointUse
http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1
from the FHIR Standard
InsurancePlan.coverage:drug-coverage.benefit.typeextensibleInsurancePlanType
http://terminology.hl7.org/ValueSet/insuranceplan-type
InsurancePlan.coverage:drug-coverage.benefit:drug-plan.typeextensiblePattern: drug("Drug")
http://terminology.hl7.org/ValueSet/insuranceplan-type
InsurancePlan.plan.typeextensibleInsurancePlanType
http://terminology.hl7.org/ValueSet/insuranceplan-type
InsurancePlan.plan:drug-plan.typeextensiblePattern: drug("Drug")
http://terminology.hl7.org/ValueSet/insuranceplan-type
InsurancePlan.plan:drug-plan.specificCost.categoryextensiblePharmacyBenefitTypeVS (a valid code from Codes for pharmacy benefit types)
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/PharmacyBenefitTypeVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.typeextensibleDrugTierVS (a valid code from Codes for medication drug tiers in health plans)
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/DrugTierVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost.typeextensibleBenefitCostTypeVS (a valid code from Codes for benefit type of cost)
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.typeextensiblePattern: copay
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.qualifiersrequiredCopayOptionVS
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:copay.value.comparatorrequiredQuantityComparator
http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1
from the FHIR Standard
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.typeextensiblePattern: coinsurance
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/BenefitCostTypeVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.qualifiersrequiredCoinsuranceOptionVS
http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS
from this IG
InsurancePlan.plan:drug-plan.specificCost.benefit.cost:coinsurance.value.comparatorrequiredQuantityComparator
http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron