Drug Plan Tier Benefits

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_tier_benefits`	`plan:drug-plan.specificCost.benefit` of the Payer Insurance Plan	1..*, must support

A tier benefit is one drug tier within one pharmacy benefit type. It has no fields of its own beyond the tier; it exists to hang the copay and coinsurance on.

drug_plan_tier_benefits

One row per drug tier under a pharmacy benefit type.

Column	Required	Format / values	Example
`drug_plan_id`	Yes	key from `drug_plans`	`DP-DSNP`
`pharmacy_benefit_type`	Yes	key from `drug_plan_specific_costs`, with `drug_plan_id`	`1-month-in-retail`
`drug_tier`	Yes	see Drug tiers; becomes `type`	`generic`
`is_deleted`	If retracting	`true` retracts this row and its costs	`true`

A row is identified by drug_plan_id, pharmacy_benefit_type and drug_tier together.
Every row needs at least one cost under it.
The tiers a drug plan lists here are the ones its formulary items may name in drug_tier.

Drug tiers

drug_tier is the plan's own tier for the drug. The IG ships an example set, DrugTierVS, and expects plans to use their own where these do not fit. Send the code your plan documents use; if it is not one of these, tell us during scoping so the tier is registered.

Value	Meaning
`preferred-generic`	commonly prescribed generic drugs
`generic`	generic drugs that cost more than preferred generics
`non-preferred-generic`	generic drugs that cost more than the generic tier
`preferred-brand`	brand-name drugs preferred by the plan
`brand`	brand-name drugs that cost more than preferred brands
`non-preferred-brand`	brand-name drugs that cost more than the brand tier
`preferred`	drugs preferred by the plan, where tiers are not split by generic and brand
`non-preferred`	drugs that cost more than the preferred tier
`specialty`	drugs for complex conditions, generic or brand, often with special handling
`zero-cost-share-preventative`	preventive drugs available at no cost
`medical-service`	drugs administered by a clinician or in a facility, covered under the medical benefit

These resources are served by Patient Access.