{ "resourceType" : "InsurancePlan", "id" : "PayerInsurancePlanA3001", "meta" : { "lastUpdated" : "2021-08-22T18:36:03.000+00:00", "profile" : ["http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PayerInsurancePlan"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: InsurancePlan PayerInsurancePlanA3001

Last updated: 2021-08-22 18:36:03+0000

Profile: Payer Insurance Plan

identifier: A3001

status: Active

type: Medicare Advantage

name: Sample Medicare Advantage Plan A3001

period: 2021-01-01 --> 2021-12-31

coverageArea: Location United States Area

contact

purpose: Patient

telecom: +1 (888) 555-3001

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 D3001

type: drug policy

Benefits

-Type
*Drug

plan

type: Drug

specificCost

category: 1 month in network retail

benefit

type: Brand

cost

type: Copay

qualifiers: No Charge

value: 0 $ (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: 0 $ (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: 0 $ (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: 0 $ (Details: unknown codeUSD = 'United States dollar')

cost

type: Coinsurance

qualifiers: After Deductible

value: 0 % (Details: UCUM code% = '%')

" }, "identifier" : [{ "value" : "A3001" }], "status" : "active", "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pdex-plan-net/CodeSystem/InsuranceProductTypeCS", "code" : "mediadv" }] }], "name" : "Sample Medicare Advantage Plan A3001", "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) 555-3001" }] }, { "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/FormularyD3001" } }], "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" : "brand", "display" : "Brand" }] }, "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" : 0, "unit" : "$", "system" : "urn:iso:std:iso:4217", "code" : "USD" } }, { "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE", "code" : "coinsurance", "display" : "Coinsurance" }] }, "qualifiers" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE", "code" : "after-deductible", "display" : "After Deductible" }] }], "value" : { "value" : 0, "system" : "http://unitsofmeasure.org", "code" : "%" } }] }] }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE", "code" : "1-month-out-retail", "display" : "1 month out of network retail" }] }, "benefit" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE", "code" : "generic", "display" : "Generic" }] }, "cost" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE", "code" : "copay", "display" : "Copay" }] }, "qualifiers" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE", "code" : "no-charge", "display" : "No Charge" }] }], "value" : { "value" : 0, "unit" : "$", "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" : "3-month-in-retail", "display" : "3 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" : 0, "unit" : "$", "system" : "urn:iso:std:iso:4217", "code" : "USD" } }, { "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE", "code" : "coinsurance", "display" : "Coinsurance" }] }, "qualifiers" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE", "code" : "after-deductible", "display" : "After Deductible" }] }], "value" : { "value" : 0, "system" : "http://unitsofmeasure.org", "code" : "%" } }] }] }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyBenefitTypeCS-TEMPORARY-TRIAL-USE", "code" : "3-month-out-retail", "display" : "3 month out of network retail" }] }, "benefit" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS-TEMPORARY-TRIAL-USE", "code" : "generic", "display" : "Generic" }] }, "cost" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-BenefitCostTypeCS-TEMPORARY-TRIAL-USE", "code" : "copay", "display" : "Copay" }] }, "qualifiers" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE", "code" : "no-charge", "display" : "No Charge" }] }], "value" : { "value" : 0, "unit" : "$", "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" : "%" } }] }] }] }] }