For AI agents: the documentation index is at /docs/payerbox/llms.txt. A Markdown version of this page is available at /docs/payerbox/data-integration/drug-formulary/payer-plans/drug-plan-tier-costs.md or by requesting it with the Accept: text/markdown header.
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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.

DatasetUS Drug Formulary STU 2.1.0 target elementCardinality
drug_plan_tier_costsplan:drug-plan.specificCost.benefit.cost of the Payer Insurance Plan, slices copay and coinsurance1..*; 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.

drug_plan_tier_costs.csv Data template with example rows
ColumnRequiredFormat / valuesExample
drug_plan_idYeskey from drug_plansDP-DSNP
pharmacy_benefit_typeYeswith drug_plan_id and drug_tier, the key of the tier in drug_plan_tier_benefits1-month-in-retail
drug_tierYessee abovegeneric
cost_typeYescopay or coinsurance; which slice the row fillscopay
valueYesdecimal; US dollars for a copay, percent 0 to 100 for a coinsurance5.00
optionYesfor 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 CoinsuranceOptionVScharge
applicabilityIf not impliedin-network, out-of-network, other insuranceplan-applicability; derived from the -in- or -out- in the pharmacy benefit type when blank
is_deletedIf retractingtrue retracts this rowtrue
  • 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 of either is rejected.
  • 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.
  • 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.
  • Payerbox writes the copay as a money quantity in USD and the coinsurance as a percentage, and sets the cost type from cost_type.

These resources are served by Patient Access.

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