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

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## : Coverage Plan V3002 - JSON Representation

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    {
      "resourceType" : "List",
      "id" : "CoveragePlanV3002",
      "meta" : {
        "versionId" : "1",
        "lastUpdated" : "2021-08-04T18:36:03.000+00:00",
        "profile" : [
          "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-CoveragePlan"
        ]
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      },
      "extension" : [
        {
          "extension" : [
            {
              "url" : "drugTierID",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
                    "code" : "generic",
                    "display" : "Generic"
                  }
                ]
              }
            },
            {
              "url" : "mailOrder",
              "valueBoolean" : true
            },
            {
              "extension" : [
                {
                  "url" : "pharmacyType",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                        "code" : "1-month-in-retail",
                        "display" : "1 month in network retail"
                      }
                    ]
                  }
                },
                {
                  "url" : "copayAmount",
                  "valueMoney" : {
                    "value" : 10
                  }
                },
                {
                  "url" : "copayOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                        "code" : "before-deductible",
                        "display" : "Before Deductible"
                      }
                    ]
                  }
                },
                {
                  "url" : "coinsuranceRate",
                  "valueDecimal" : 1
                },
                {
                  "url" : "coinsuranceOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                        "code" : "after-deductible",
                        "display" : "After Deductible"
                      }
                    ]
                  }
                }
              ],
              "url" : "costSharing"
            },
            {
              "extension" : [
                {
                  "url" : "pharmacyType",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                        "code" : "1-month-out-retail",
                        "display" : "1 month out of network retail"
                      }
                    ]
                  }
                },
                {
                  "url" : "copayAmount",
                  "valueMoney" : {
                    "value" : 0
                  }
                },
                {
                  "url" : "copayOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                        "code" : "no-charge",
                        "display" : "No Charge"
                      }
                    ]
                  }
                },
                {
                  "url" : "coinsuranceRate",
                  "valueDecimal" : 0
                },
                {
                  "url" : "coinsuranceOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                        "code" : "after-deductible",
                        "display" : "After Deductible"
                      }
                    ]
                  }
                }
              ],
              "url" : "costSharing"
            },
            {
              "extension" : [
                {
                  "url" : "pharmacyType",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                        "code" : "3-month-in-retail",
                        "display" : "3 month in network retail"
                      }
                    ]
                  }
                },
                {
                  "url" : "copayAmount",
                  "valueMoney" : {
                    "value" : 0
                  }
                },
                {
                  "url" : "copayOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                        "code" : "no-charge",
                        "display" : "No Charge"
                      }
                    ]
                  }
                },
                {
                  "url" : "coinsuranceRate",
                  "valueDecimal" : 0
                },
                {
                  "url" : "coinsuranceOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                        "code" : "after-deductible",
                        "display" : "After Deductible"
                      }
                    ]
                  }
                }
              ],
              "url" : "costSharing"
            },
            {
              "extension" : [
                {
                  "url" : "pharmacyType",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
                        "code" : "3-month-out-retail",
                        "display" : "3 month out of network retail"
                      }
                    ]
                  }
                },
                {
                  "url" : "copayAmount",
                  "valueMoney" : {
                    "value" : 0
                  }
                },
                {
                  "url" : "copayOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
                        "code" : "no-charge",
                        "display" : "No Charge"
                      }
                    ]
                  }
                },
                {
                  "url" : "coinsuranceRate",
                  "valueDecimal" : 0
                },
                {
                  "url" : "coinsuranceOption",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
                        "code" : "after-deductible",
                        "display" : "After Deductible"
                      }
                    ]
                  }
                }
              ],
              "url" : "costSharing"
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-DrugTierDefinition-extension"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-MarketingURL-extension",
          "valueUrl" : "https://content.carefirst.com/sbc/D,$0/%20D,$0/%20D,$0/%20D,$0/%20D,$0B+"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyURL-extension",
          "valueUrl" : "http://url/to/formulary/information"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-SummaryURL-extension",
          "valueUrl" : "http://url/to/formulary/information"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-EmailPlanContact-extension",
          "valueUrl" : "mailto:Patrick.Breen@carefirst.com"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-Network-extension",
          "valueString" : "PREFERRED"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-PlanIDType-extension",
          "valueString" : "HIOS-PLAN-ID"
        }
      ],
      "identifier" : [
        {
          "value" : "test1"
        }
      ],
      "status" : "current",
      "mode" : "snapshot",
      "title" : "Sample Gold Health Plan",
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "DRUGPOL",
            "display" : "drug policy"
          }
        ]
      },
      "date" : "2015-06-12"
    }