DaVinci Payer Data Exchange (PDex) US Drug Formulary
1.1.0 - STU 1.1

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## : Coverage Plan V3001 - XML Representation

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    <List xmlns="http://hl7.org/fhir">
      <id value="CoveragePlanV3001"/>
      <meta>
        <versionId value="1"/>
        <lastUpdated value="2021-08-04T18:36:03.000+00:00"/>
        <profile
                 value="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"/>
      </meta>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><h2>Sample Gold Health Plan</h2><table class="clstu"><tr><td>Date: 2015-06-12Mode: snapshotStatus: currentCode: drug policy</td></tr><tr><td></td></tr></table><table class="grid"><tr style="backgound-color: #eeeeee"><td><b>Items</b></td></tr></table></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension">
        <extension url="drugTierID">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"/>
              <code value="generic"/>
              <display value="Generic"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="mailOrder">
          <valueBoolean value="true"/>
        </extension>
        <extension url="costSharing">
          <extension url="pharmacyType">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
                <code value="1-month-in-retail"/>
                <display value="1 month in network retail"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="copayAmount">
            <valueMoney>
              <value value="0"/>
            </valueMoney>
          </extension>
          <extension url="copayOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
                <code value="no-charge"/>
                <display value="No Charge"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="coinsuranceRate">
            <valueDecimal value="0"/>
          </extension>
          <extension url="coinsuranceOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
                <code value="after-deductible"/>
                <display value="After Deductible"/>
              </coding>
            </valueCodeableConcept>
          </extension>
        </extension>
        <extension url="costSharing">
          <extension url="pharmacyType">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
                <code value="1-month-out-retail"/>
                <display value="1 month out of network retail"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="copayAmount">
            <valueMoney>
              <value value="0"/>
            </valueMoney>
          </extension>
          <extension url="copayOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
                <code value="no-charge"/>
                <display value="No Charge"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="coinsuranceRate">
            <valueDecimal value="0"/>
          </extension>
          <extension url="coinsuranceOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
                <code value="after-deductible"/>
                <display value="After Deductible"/>
              </coding>
            </valueCodeableConcept>
          </extension>
        </extension>
        <extension url="costSharing">
          <extension url="pharmacyType">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
                <code value="3-month-in-retail"/>
                <display value="3 month in network retail"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="copayAmount">
            <valueMoney>
              <value value="0"/>
            </valueMoney>
          </extension>
          <extension url="copayOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
                <code value="no-charge"/>
                <display value="No Charge"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="coinsuranceRate">
            <valueDecimal value="0"/>
          </extension>
          <extension url="coinsuranceOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
                <code value="after-deductible"/>
                <display value="After Deductible"/>
              </coding>
            </valueCodeableConcept>
          </extension>
        </extension>
        <extension url="costSharing">
          <extension url="pharmacyType">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"/>
                <code value="3-month-out-retail"/>
                <display value="3 month out of network retail"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="copayAmount">
            <valueMoney>
              <value value="0"/>
            </valueMoney>
          </extension>
          <extension url="copayOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"/>
                <code value="no-charge"/>
                <display value="No Charge"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="coinsuranceRate">
            <valueDecimal value="0"/>
          </extension>
          <extension url="coinsuranceOption">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"/>
                <code value="after-deductible"/>
                <display value="After Deductible"/>
              </coding>
            </valueCodeableConcept>
          </extension>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension">
        <valueUrl
                  value="https://content.carefirst.com/sbc/D,$0/%20D,$0/%20D,$0/%20D,$0/%20D,$0B+"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension">
        <valueUrl value="http://url/to/formulary/information"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension">
        <valueUrl value="http://url/to/health/plan/information"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension">
        <valueUrl value="mailto:Patrick.Breen@carefirst.com"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension">
        <valueString value="PREFERRED"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension">
        <valueString value="HIOS-PLAN-ID"/>
      </extension>
      <identifier>
        <value value="test"/>
      </identifier>
      <status value="current"/>
      <mode value="snapshot"/>
      <title value="Sample Gold Health Plan"/>
      <code>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="DRUGPOL"/>
          <display value="drug policy"/>
        </coding>
      </code>
      <date value="2015-06-12"/>
    </List>