HL7 FHIR® Implementation Guide: DaVinci Payer Data Exchange US Drug Formulary, Release 1 STU2 - US Realm

DESCRIPTION

This project defines a FHIR interface to a health insurer's drug formulary information for patients/consumers. A drug formulary is a list of brand-name and generic prescription drugs a health insurer agrees to pay for, at least partially, as part of health insurance coverage. Drug formularies are developed based on the efficacy, safety and cost of drugs. The primary use cases for this FHIR interface enable consumers/members/patients to understand the costs and alternatives for drugs that have been prescribed, and to compare their drug costs across different insurance plans.

 

See the specification at http://hl7.org/fhir/us/Davinci-drug-formulary/STU2

ALTERNATIVE NAMES

HL7 FHIR® Implementation Guide: DaVinci Payer Data Exchange US Drug Formulary, Release 1 STU2 - US Realm may also go by the following names or acronyms:

BENEFITS

• Enables consumers/members/patients to understand the costs and alternatives for drugs that have been prescribed, and to compare their drug costs across different insurance plans.

IMPLEMENTATIONS/CASE STUDIES

• Med Copays under Health Plan
  • This use case allows a member to determine the plan level estimated costs of each of their medications under the drug coverage of their current health plan. The mobile application retrieves the member's medication list from an electronic health record system where the member's patient data is stored. This security and privacy of a patient's access to their health information is beyond the scope of this Implementation Guide. The member could also independently maintain their medication list in the mobile application or elsewhere. The mobile application queries the formulary service for cost information about the drugs that the member takes and provides the the plan level estimated cost for each medication under the member's current health plan.
  • Note that for this use case the coverage plan could provide authenticated or open access to the plan formulary, and the privacy of the member's data is protected.
• Shopping for Health Plans
  • This use case allows a consumer to compare the drug coverage of several different health plans and determine which plan has the lowest plan level estimated cost, personalized to the consumers's set of medications. The mobile application retrieves the consumer's medication list from an electronic health record system where the consumer's patient data is stored. This security and privacy of a patient's access to their health information is beyond the scope of this Implementation Guide. The consumer could also independently maintain their medication list in the mobile application or elsewhere. The mobile application identifies the relevant formulary endpoint through means that are beyond the scope of this implementation guide (see Disclaimers and Assumptions). For each payer, the mobile application queries the payer's formulary service to retrieve the list of health plans provided by that payer. Then, for each plan,the mobile application queries the formulary service to retrieve the plan-level estimated costs specific to the consumer's medication list.
  • Access to the formulary service should not require authentication, and the server should not maintain any records that could associate the consumer with the medication list that was queried.

DEVELOPMENT BACKGROUND

This Implementation Guide was developed as part of the da Vinci project to meet use cases defined in the CMS Interoperability Rule.

 

RELATED DOCUMENTS

HL7 FHIR® Implementation Guide: DaVinci Payer Data Exchange US Drug Formulary, Release 1 STU2 - US Realm

(Download) (54 KB)

STU DOCUMENTS

	HL7 FHIR® Implementation Guide: DaVinci Payer Data Exchange US Drug Formulary, Release 1 STU2- US Realm See the standard at http://hl7.org/fhir/us/davinci-drug-formulary/STU2.	(Submit Feedback on STU)
	HL7 FHIR® Implementation Guide: DaVinci Payer Data Exchange US Drug Formulary, Release 1 - US Realm Please see the resource detail for link and download instructions.	(Submit Feedback on STU)

TOPICS

• Financial Management
• Pharmacy

BALLOT TYPE

• STU

STATUS DATE

2020-01-21

RESPONSIBLE WORK GROUPS

PRODUCT TYPE

• Implementation Guide

STAKEHOLDERS

• Clinical and Public Health Laboratories
• Clinical Decision Support Systems Vendors
• Health Care IT Vendors
• Healthcare Institutions
• Immunization Registries
• Lab Vendors
• Medical Imaging Service Providers
• Payors
• Quality Reporting Agencies
• Regulatory Agency

FAMILY

• FHIR

CURRENT STATE

• Active

REALM

• US Realm