Drug Formulary
Datasets
Built to Da Vinci PDex US Drug Formulary STU 2.1.0. A formulary is the list of drugs a plan pays for, with the tier, cost sharing and coverage rules for each. The IG splits it into four resources, and the feed has one dataset per resource.
| Dataset | US Drug Formulary STU 2.1.0 target profile |
|---|---|
payer_plans | Payer Insurance Plan (InsurancePlan), with its coverage area as Insurance Plan Location |
formularies | Formulary (InsurancePlan) |
formulary_drugs | Formulary Drug (MedicationKnowledge) |
formulary_items | Formulary Item (Basic) |
The four fit together this way. A payer plan states its drug benefit as a cost-sharing table, one cell per pharmacy benefit type and drug tier, and points at the formulary it uses. A formulary is a named list for a plan year. A formulary drug is one prescribable product, identified by RxNorm. A formulary item is the row of the list: this drug, on this formulary, in this tier, with these requirements.
Data conventions
| Rule | Detail |
|---|---|
| Scope | Medicare Advantage lines with Part D drug coverage. Covered drugs only: a drug that is not on the formulary is absent, not listed as excluded. |
| Delivery | Full snapshot each extract, not deltas. A drug removed during the plan year stays in the snapshot as retired with an availability_end until the plan year ends, so a member can still see it was covered; a plan or formulary that ended is likewise retired. Rows absent from a snapshot are removed. |
| Keys | plan_id, formulary_id and drug_id are your identifiers and stay stable across snapshots. A plan that also appears in the Provider Directory uses the same plan_id there, and *_org_npi and network_ids are keys into that feed's organizations and networks. |
| Codes | Send the code, not the description. Drugs are RxNorm; Payerbox derives every display from its terminology service. |
| Multiple values | ;-separated, positionally aligned across companion columns. |
| Amounts | Copays are decimal US dollars; coinsurance is a percentage, 0 to 100, no % sign. |
| Dates | YYYY-MM-DD. |
| Not PHI | A formulary is public information and is also served unauthenticated. It carries no member data. |
These resources are served by Patient Access.