DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1 US

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: Formulary

Official URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Formulary Version: 2.1.0
Standards status: Trial-use Computable Name: Formulary
Other Identifiers: OID:2.25.74595174031514506193398850787025340071.42.6

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.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
... type SΣ 1..1 CodeableConcept Plan type
Binding: InsurancePlanType (example): Used to categorize the product/plan.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DRUGPOL
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... name SΣC 0..1 string Official name
... period S 0..1 Period When the product is available
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of plan
Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
...... version 0..1 string Version of the system - if relevant
...... 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
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
... meta
.... lastUpdated S 1..1 instant When the resource version last changed
... identifier S 1..* Identifier Business Identifier for Product
... status S 1..1 code draft | active | retired | unknown
.... 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
... name S 0..1 string Official name
... period S 0..1 Period When the product is available
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... type 1..1 CodeableConcept Type of plan
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
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 1..* Identifier Business Identifier for Product
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
... type SΣ 1..1 CodeableConcept Plan type
Binding: InsurancePlanType (example): Used to categorize the product/plan.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DRUGPOL
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(Organization) Plan issuer
... administeredBy Σ 0..1 Reference(Organization) Product administrator
... coverageArea Σ 0..* Reference(Location) Where product applies
... contact 0..* BackboneElement Contact for the product
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(Endpoint) Technical endpoint
... network 0..* Reference(Organization) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
.... network 0..* Reference(Organization) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
..... requirement 0..1 string Referral requirements
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
.... type 1..1 CodeableConcept Type of plan
Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
...... version 0..1 string Version of the system - if relevant
...... 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
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... coverageArea Σ 0..* Reference(Location) Where product applies
.... network 0..* Reference(Organization) What networks provide coverage
.... generalCost 0..* BackboneElement Overall costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 0..1 CodeableConcept Type of cost
..... groupSize 0..1 positiveInt Number of enrollees
..... cost 0..1 Money Cost value
..... comment 0..1 string Additional cost information
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)
...... cost 0..* BackboneElement List of the costs
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type 1..1 CodeableConcept Type of cost
....... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
InsurancePlan.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
InsurancePlan.language Base preferred Common Languages 📍4.0.1 FHIR Std.
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.contact.​purpose Base extensible Contact entity type 📍4.0.1 FHIR Std.
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

Summary

Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 6 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
... type SΣ 1..1 CodeableConcept Plan type
Binding: InsurancePlanType (example): Used to categorize the product/plan.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DRUGPOL
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... name SΣC 0..1 string Official name
... period S 0..1 Period When the product is available
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of plan
Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
...... version 0..1 string Version of the system - if relevant
...... 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
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
... meta
.... lastUpdated S 1..1 instant When the resource version last changed
... identifier S 1..* Identifier Business Identifier for Product
... status S 1..1 code draft | active | retired | unknown
.... 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
... name S 0..1 string Official name
... period S 0..1 Period When the product is available
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... type 1..1 CodeableConcept Type of plan
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
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
Constraints: ipn-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 1..* Identifier Business Identifier for Product
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.
... type SΣ 1..1 CodeableConcept Plan type
Binding: InsurancePlanType (example): Used to categorize the product/plan.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DRUGPOL
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(Organization) Plan issuer
... administeredBy Σ 0..1 Reference(Organization) Product administrator
... coverageArea Σ 0..* Reference(Location) Where product applies
... contact 0..* BackboneElement Contact for the product
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(Endpoint) Technical endpoint
... network 0..* Reference(Organization) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
.... network 0..* Reference(Organization) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
..... requirement 0..1 string Referral requirements
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan 0..1 BackboneElement Optional non-cost related plan information indicating pharmacy benefit types and drug tiers available in the formulary
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
.... type 1..1 CodeableConcept Type of plan
Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/insurance-plan-type
...... version 0..1 string Version of the system - if relevant
...... 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
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... coverageArea Σ 0..* Reference(Location) Where product applies
.... network 0..* Reference(Organization) What networks provide coverage
.... generalCost 0..* BackboneElement Overall costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 0..1 CodeableConcept Type of cost
..... groupSize 0..1 positiveInt Number of enrollees
..... cost 0..1 Money Cost value
..... comment 0..1 string Additional cost information
.... specificCost 0..* BackboneElement Pharmacy benefit type specific cost
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
Binding: Pharmacy benefit types (extensible)
..... benefit 0..* BackboneElement Drug tier benefit
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
Binding: Drug tier of medication in health plan (extensible)
...... cost 0..* BackboneElement List of the costs
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type 1..1 CodeableConcept Type of cost
....... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
InsurancePlan.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
InsurancePlan.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
InsurancePlan.language Base preferred Common Languages 📍4.0.1 FHIR Std.
InsurancePlan.status Base required PublicationStatus 📍4.0.1 FHIR Std.
InsurancePlan.type Base example Insurance plan type 📍4.0.1 FHIR Std.
InsurancePlan.contact.​purpose Base extensible Contact entity type 📍4.0.1 FHIR Std.
InsurancePlan.plan.specificCost.​category Base extensible Pharmacy benefit types 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.type Base extensible Drug tier of medication in health plan 📦2.1.0 This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

Summary

Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 6 elements

 

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