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

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## Extension: 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.

The official URL for this extension is:

    http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension

Status: active
Extension maintained by: HL7 Pharmacy Working Group

Context of Use

This extension may be used on the following element(s):

- Element

Usage info

Usage:

- Use this Extension: Formulary Coverage Plan
- Examples for this Extension: List/CoveragePlanV3001, List/CoveragePlanV3002, List/CoveragePlanV3004t, List/covplanV1002

### Formal Views of Extension Content

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

- Text Summary
- Differential Table
- Snapshot Table
- All

This structure is derived from Extension

Summary

Mandatory: 4 elements (10 nested mandatory elements)
Fixed Value: 9 elements
Prohibited: 9 elements

This structure is derived from Extension

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Extension |  | 0..* | Extension | Drug Tier Definition
extension |  | 2..* | Extension | Extension
extension:drugTierID |  | 1..1 | Extension | Drug Tier ID
extension |  | 0..0 |  |
url |  | 1..1 | uri | "drugTierID"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Drug tier of medication in health plan (extensible)
extension:mailOrder |  | 1..1 | Extension | Mail Order
extension |  | 0..0 |  |
url |  | 1..1 | uri | "mailOrder"
value[x] |  | 1..1 | boolean | Value of extension
extension:costSharing |  | 0..* | Extension | Extension
extension |  | 5..* | Extension | Extension
extension:pharmacyType |  | 1..1 | Extension | Pharmacy Type
extension |  | 0..0 |  |
url |  | 1..1 | uri | "pharmacyType"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Type of pharmacies (extensible)
extension:copayAmount |  | 1..1 | Extension | Copay Amount
extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayAmount"
value[x] |  | 1..1 | Money | Value of extension
extension:copayOption |  | 1..1 | Extension | Copay Options
extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier of copay amount (required)
extension:coinsuranceRate |  | 1..1 | Extension | Co-Insurance Rate
extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceRate"
value[x] |  | 1..1 | decimal | Value of extension
extension:coinsuranceOption |  | 1..1 | Extension | Co-Insurance Option
extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier for coinsurance rate (required)
url |  | 1..1 | uri | "costSharing"
value[x] |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
value[x] |  | 0..0 |  |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Extension |  | 0..* | Extension | Drug Tier Definition
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:drugTierID |  | 1..1 | Extension | Drug Tier ID
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "drugTierID"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Drug tier of medication in health plan (extensible)
extension:mailOrder |  | 1..1 | Extension | Mail Order
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "mailOrder"
value[x] |  | 1..1 | boolean | Value of extension
extension:costSharing |  | 0..* | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 5..* | Extension | Extension Slice: Unordered, Open by value:url
extension:pharmacyType |  | 1..1 | Extension | Pharmacy Type
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "pharmacyType"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Type of pharmacies (extensible)
extension:copayAmount |  | 1..1 | Extension | Copay Amount
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayAmount"
value[x] |  | 1..1 | Money | Value of extension
extension:copayOption |  | 1..1 | Extension | Copay Options
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier of copay amount (required)
extension:coinsuranceRate |  | 1..1 | Extension | Co-Insurance Rate
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceRate"
value[x] |  | 1..1 | decimal | Value of extension
extension:coinsuranceOption |  | 1..1 | Extension | Co-Insurance Option
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier for coinsurance rate (required)
url |  | 1..1 | uri | "costSharing"
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
Documentation for this format

This structure is derived from Extension

Summary

Mandatory: 4 elements (10 nested mandatory elements)
Fixed Value: 9 elements
Prohibited: 9 elements

Differential View

This structure is derived from Extension

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Extension |  | 0..* | Extension | Drug Tier Definition
extension |  | 2..* | Extension | Extension
extension:drugTierID |  | 1..1 | Extension | Drug Tier ID
extension |  | 0..0 |  |
url |  | 1..1 | uri | "drugTierID"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Drug tier of medication in health plan (extensible)
extension:mailOrder |  | 1..1 | Extension | Mail Order
extension |  | 0..0 |  |
url |  | 1..1 | uri | "mailOrder"
value[x] |  | 1..1 | boolean | Value of extension
extension:costSharing |  | 0..* | Extension | Extension
extension |  | 5..* | Extension | Extension
extension:pharmacyType |  | 1..1 | Extension | Pharmacy Type
extension |  | 0..0 |  |
url |  | 1..1 | uri | "pharmacyType"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Type of pharmacies (extensible)
extension:copayAmount |  | 1..1 | Extension | Copay Amount
extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayAmount"
value[x] |  | 1..1 | Money | Value of extension
extension:copayOption |  | 1..1 | Extension | Copay Options
extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier of copay amount (required)
extension:coinsuranceRate |  | 1..1 | Extension | Co-Insurance Rate
extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceRate"
value[x] |  | 1..1 | decimal | Value of extension
extension:coinsuranceOption |  | 1..1 | Extension | Co-Insurance Option
extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier for coinsurance rate (required)
url |  | 1..1 | uri | "costSharing"
value[x] |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
value[x] |  | 0..0 |  |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Extension |  | 0..* | Extension | Drug Tier Definition
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:drugTierID |  | 1..1 | Extension | Drug Tier ID
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "drugTierID"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Drug tier of medication in health plan (extensible)
extension:mailOrder |  | 1..1 | Extension | Mail Order
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "mailOrder"
value[x] |  | 1..1 | boolean | Value of extension
extension:costSharing |  | 0..* | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 5..* | Extension | Extension Slice: Unordered, Open by value:url
extension:pharmacyType |  | 1..1 | Extension | Pharmacy Type
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "pharmacyType"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Type of pharmacies (extensible)
extension:copayAmount |  | 1..1 | Extension | Copay Amount
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayAmount"
value[x] |  | 1..1 | Money | Value of extension
extension:copayOption |  | 1..1 | Extension | Copay Options
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "copayOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier of copay amount (required)
extension:coinsuranceRate |  | 1..1 | Extension | Co-Insurance Rate
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceRate"
value[x] |  | 1..1 | decimal | Value of extension
extension:coinsuranceOption |  | 1..1 | Extension | Co-Insurance Option
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "coinsuranceOption"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Qualifier for coinsurance rate (required)
url |  | 1..1 | uri | "costSharing"
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Extension.extension:drugTierID.value[x] | extensible | DrugTierVS
Extension.extension:costSharing.extension:pharmacyType.value[x] | extensible | PharmacyTypeVS
Extension.extension:costSharing.extension:copayOption.value[x] | required | CopayOptionVS
Extension.extension:costSharing.extension:coinsuranceOption.value[x] | required | CoinsuranceOptionVS