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

Publication Build: This will be filled in by the publication tooling

## Example List: Coverage Plan V1002

## Sample Gold Health Plan

Date: 2015-06-12Mode: snapshotStatus: currentCode: drug policy

Items

### Notes:

Field | Value
resourceType | "List"
meta.profile[0] | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
id | "covplanV1002"
identifier[0].value | HIOS-PLAN-ID
status | "current"
mode | "snapshot"
title | "Sample Gold Health Plan"
date | "2015-06-12"
entry[0].item.reference | "MedicationKnowledge/formularydrugV1002"
extension[0].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
extension[0].extension[0].url | "drugTierID"
extension[0].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS"
extension[0].extension[0].valueCodeableConcept.coding[0].code | #brand
extension[0].extension[0].valueCodeableConcept.coding[0].display | "Brand"
extension[0].extension[1].url | "mailOrder"
extension[0].extension[1].valueBoolean | "false"
extension[0].extension[2].url | "costSharing"
extension[0].extension[2].extension[0].url | "pharmacyType"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS"
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].code | #1-month-in-retail
extension[0].extension[2].extension[0].valueCodeableConcept.coding[0].display | "1 month in network retail"
extension[0].extension[2].extension[1].url | "copayAmount"
extension[0].extension[2].extension[1].valueMoney.value | 20
extension[0].extension[2].extension[2].url | "coinsuranceRate"
extension[0].extension[2].extension[2].valueDecimal | "0.2"
extension[0].extension[2].extension[3].url | "copayOption"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS"
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].code | #after-deductible
extension[0].extension[2].extension[3].valueCodeableConcept.coding[0].display | "After Deductible"
extension[0].extension[2].extension[4].url | "coinsuranceOption"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].system | "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS"
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].code | #after-deductible
extension[0].extension[2].extension[4].valueCodeableConcept.coding[0].display | "After Deductible"
extension[1].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension"
extension[1].valueString | "http://url/to/health/plan/information"
extension[2].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension"
extension[2].valueString | "http://url/to/health/plan/information"
extension[3].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension"
extension[3].valueString | "http://url/to/formulary/information"
extension[4].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension"
extension[4].valueString | "email@address.com"
extension[5].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension"
extension[5].valueString | "PREFERRED"
extension[6].url | "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension"
extension[6].valueString | "HIOS-PLAN-ID"