Drug Plan Specific Costs
Datasets
Part of the Payer Plans group of the Drug Formulary feed, built to Da Vinci PDex US Drug Formulary STU 2.1.0. The feed's data conventions apply.
| Dataset | US Drug Formulary STU 2.1.0 target element | Cardinality |
|---|---|---|
drug_plan_specific_costs | plan:drug-plan.specificCost of the Payer Insurance Plan | 1..*, must support |
A specific cost is one pharmacy benefit type of the drug plan: a channel and supply length, such as a one-month supply at an in-network retail pharmacy. The tiers and their amounts hang below it.
drug_plan_specific_costs
One row per pharmacy benefit type of a drug plan.
| Column | Required | Format / values | Example |
|---|---|---|---|
drug_plan_id | Yes | key from drug_plans | DP-DSNP |
pharmacy_benefit_type | Yes | see Pharmacy benefit types; becomes category | 1-month-in-retail |
is_deleted | If retracting | true retracts this row and the tiers under it | true |
- A row is identified by
drug_plan_idandpharmacy_benefit_typetogether. - Every row needs at least one tier benefit under it.
- The pharmacy benefit types a drug plan lists here are the ones its formulary items may name in
pharmacy_benefit_types.
Pharmacy benefit types
pharmacy_benefit_type says through which channel and supply length a cost applies. The set is the IG's own PharmacyBenefitTypeVS, extensible: a plan may add its own codes, and then defines them in a code system Payerbox registers per engagement.
| Value | Meaning |
|---|---|
1-month-in-retail | 1-month supply, in-network retail pharmacy |
1-month-out-retail | 1-month supply, out-of-network retail pharmacy |
1-month-in-mail | 1-month supply, in-network mail order |
1-month-out-mail | 1-month supply, out-of-network mail order |
3-month-in-retail | 3-month supply, in-network retail pharmacy |
3-month-out-retail | 3-month supply, out-of-network retail pharmacy |
3-month-in-mail | 3-month supply, in-network mail order |
3-month-out-mail | 3-month supply, out-of-network mail order |
These resources are served by Patient Access.