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 |
Medicare Part D plans price preferred and standard network pharmacies differently, and some price a 2-month supply; the IG's set has neither. Where your plan does, send the codes your plan documents use, as they are spelled there. Payerbox publishes any code outside the IG's set under a code system registered for your plan at scoping, so the set is yours to define. A common shape, and the one the templates use:
| Value | Meaning |
|---|---|
1-month-preferred-retail | 1-month supply, preferred in-network retail pharmacy |
1-month-standard-retail | 1-month supply, standard in-network retail pharmacy |
1-month-preferred-mail | 1-month supply, preferred mail order |
1-month-standard-mail | 1-month supply, standard mail order |
3-month-preferred-retail, 3-month-standard-retail, 3-month-preferred-mail, 3-month-standard-mail | the same for a 3-month supply |
Other payers' live APIs use the same idea with their own spellings, such as 1-month-pref-retail, 1-month-stand-mail or 2-month-stand-retail; those work as well. A plan without preferred pricing uses the IG codes above. Do not mix the IG's codes and your own within one drug plan.
These resources are served by Patient Access.