Drug Plan Tier 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_tier_costs`	`plan:drug-plan.specificCost.benefit.cost` of the Payer Insurance Plan, slices `copay` and `coinsurance`	1..*; each slice 0..1, must support

A cost is one amount a member pays for a tier: a flat copay or a coinsurance percentage. The profile slices cost into those two, each at most once per tier, so a tier has one or two rows here.

drug_plan_tier_costs

One row per cost of a tier.

Column	Required	Format / values	Example
`drug_plan_id`	Yes	key from `drug_plans`	`DP-DSNP`
`pharmacy_benefit_type`	Yes	with `drug_plan_id` and `drug_tier`, the key of the tier in `drug_plan_tier_benefits`	`1-month-in-retail`
`drug_tier`	Yes	see above	`generic`
`cost_type`	Yes	`copay` or `coinsurance`; which slice the row fills	`copay`
`value`	Yes	decimal; US dollars for a copay, percent `0` to `100` for a coinsurance	`5.00`
`option`	Yes	for `copay`: `after-deductible`, `before-deductible`, `no-charge`, `no-charge-after-deductible`, `charge`, `copay-not-applicable`, `deductible-waived` CopayOptionVS; for `coinsurance`: `after-deductible`, `no-charge`, `no-charge-after-deductible`, `charge`, `coinsurance-not-applicable`, `deductible-waived` CoinsuranceOptionVS	`charge`
`min_value`	If a coinsurance has a floor	decimal, US dollars; the least a member pays for a fill
`max_value`	If a coinsurance has a cap	decimal, US dollars; the most a member pays for a fill	`5.10`
`applicability`	If not implied	`in-network`, `out-of-network`, `other` insuranceplan-applicability; derived from the pharmacy benefit type when blank: `-out-` is out-of-network, `-in-` and a plan's own preferred or standard code are in-network
`is_deleted`	If retracting	`true` retracts this row	`true`

A row is identified by the tier's three keys plus cost_type. At most one copay and one coinsurance row per tier: a second row of the same type is merged into the first, one value is kept and the disagreement is reported as merge_conflict.
value is mandatory on both slices, so a tier with no copay says so with 0.00 and the option copay-not-applicable, not by leaving the copay row out; likewise 0 with coinsurance-not-applicable. A free tier is 0.00 with no-charge.
Send the cost sharing of the initial coverage phase, one set per tier. Part D has three phases, and two are fixed by law: in the deductible phase the member pays the full price until the deductible in drug_plan_general_costs is met, and in the catastrophic phase the member pays nothing. Only the initial phase is plan-specific, and it is what the IG's one amount per tier represents. Do not send rows for the other phases.
option is the qualifier the profile requires on every cost: how the amount interacts with the deductible. The allowed values differ by cost_type, as listed. A tier the deductible applies to is after-deductible; a tier exempt from it is charge, or no-charge when the amount is zero.
min_value and max_value are for a coinsurance with a dollar floor or ceiling, such as 25 percent up to $5.10 a fill. The IG's copay value carries a comparator, so Payerbox publishes a cap as a copay of <= 5.10 beside the coinsurance, and a floor as >=. They are allowed only on a coinsurance row; a copay is already a fixed amount. Because the IG allows one copay per tier, the cap takes the copay's place: the tier's copay-not-applicable row, if sent, is dropped in its favor, and a tier that states a real copay amount and a cap is reported as a conflict and the cap is not published.
A drug-specific cost share that overrides the tier, such as the statutory insulin copay cap, has no place in the plan's cost table. State it on the drug's formulary item in additional_coverage_information.
Payerbox writes the copay as a money quantity in USD and the coinsurance as a percentage, and sets the cost type from cost_type.

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