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

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## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

US Drug Formulary Server Capability Statement | This Section describes the expected capabilities of the US Drug Formulary Server actor which is responsible for providing responses to the queries submitted by the US Drug Formulary Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Drug Formulary Server are defined.

### Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

DrugName | Accesses the Descriptive Name of a FormularyDrug
DrugPlan | Accesses the DrugPlan ID of a FormularyDrug
DrugTier | Accesses the DrugTier ID of a FormularyDrug

### Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

Formulary Coverage Plan | A health plan which contains links to administrative information, a list of formulary drugs covered under that plan, and a definition of drug tiers and their associated cost-sharing models.
Formulary Drug | Drug information which is part of a formulary including its RxNorm code, the PlanID of the formulary, information on prescribing limitations, and optionally drug classification and alternatives.

### Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

Drug Alternatives | Generic or Branded Drugs included within the CoveragePlan’s formulary that could be prescribed as alternatives to the current FormularyDrug.
Drug Tier Definition | A description of the drug tiers used by the formulary and how those tiers implement copay and coinsurance amounts. Drug tiers do not have any inherent meaning that is consistent across all formularies. Rather, each tier is defined using this element.
Drug Tier ID | A code that describes the coverage status of a drug in a health plan (e.g., preferred generic, specialty, etc.)
Email Plan Contact | An email address for developers/public to report mistakes in the network and formulary data. FHIR URL type can be a web-url or an e-mail address.
Formulary URL | The URL that goes directly to the formulary brochure for the specific standard plan or plan variation. If the formulary brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.
Mail Order | A Boolean indication of whether the formulary drug is available by mail order through the associated plan. The MailOrder value in FormularyDrug overrides the MailOrder value in DrugTierDefinition within the CoveragePlan.
Marketing URL | The URL that goes directly to the plan brochure for the specific standard plan or plan variation. If the plan brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.
Network | Array of Networks within a plan. If a network is not applicable for a plan, enter ‘Not applicable’ in the value string.
Plan ID | Unique, generated Plan ID number, such as HIOS ID for QHPs or Contract Number for Medicare Advantage Plans. Plan IDs must be unique within each organization that manages their formulary data.
Plan ID Type | Type of Plan ID. For all Marketplace plans this should be: HIOS-PLAN-ID. For all other plans this should be: OTHER-PLAN-ID.
Prior Authorization | A Boolean indication of whether the coverage plan imposes a prior authorization requirement on this drug.
Quantity Limit | A Boolean indication of whether the coverage plan imposes a quantity limit on this drug.
Step Therapy Limit | A Boolean indication of whether the coverage plan imposes a step therapy limit on this drug.
Summary URL | The URL that goes directly to the formulary brochure for the specific standard plan or plan variation. If the formulary brochure is available in multiple languages, this can also point to a page listing the links for the various different language versions of the document supported by the payer.

### Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

Qualifier for coinsurance rate | Qualifier for coinsurance rate
Qualifier of copay amount | Qualifier of copay amount
Drug tier of medication in health plan | The drug tier of a particular medication in a health plan. The base set are examples. Each plan may have its own controlled vocabulary.
Type of pharmacies | Types of pharmacies. Each payer will have its own controlled vocabulary.

### Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

Code for qualifier for coinsurance rate | Code for qualifier for coinsurance rate
Codes for qualifier of copay amount | Codes for qualifier of copay amount
Codes for medication drug tiers in health plans | Codes to represent the drug tier of a particular medication in a health plan. Base set are examples. Each plan may have its own controlled vocabulary.
Codes for types of pharmacies | Codes for types of Pharmacies. Each payer will have its own controlled vocabulary.

### Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Coverage Plan V1002 | Sample Gold Health Plan
Coverage Plan V3001 | Sample Gold Health Plan
Coverage Plan V3002 | Sample Gold Health Plan
Coverage Plan V3004t | BluePreferred PPO HSA Silver $3,000
Formulary Drug cmsip9 | Doxepin HCl 5 % Topical Cream
Formulary Drug V1002 | Percocet 5 MG / 325 MG Oral Tablet
Formulary Drug V3001 | Percocet 5 MG / 325 MG Oral Tablet
Formulary Drug V3002 | Tylenol Extra Strength 500 MG Oral Tablet