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Specification:

US Da Vinci Drug Formulary (FHIR)
Raised in Version:

1.0.1
Work Group:

Pharmacy
Related URL:
http://build.fhir.org/ig/HL7/davinci-pdex-formulary/ValueSet-CopayOptionVS.html
Related Artifact(s):

Qualifier of copay amount
Grouping:
- STU-1.1.0-Update
Resolution Description:

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Add the following to the Qualifier of copay amount:

Charge - the consumer always pays just the copay and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible).

Add the following to the Qualifier of coinsurance rate:

Charge - the consumer always pays just the coinsurance and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible).

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Add the following to the Qualifier of copay amount: Charge - the consumer always pays just the copay and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible). Add the following to the Qualifier of coinsurance rate: Charge - the consumer always pays just the coinsurance and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible).
Resolution Vote:
Dave Hill / Tim McNeil : 8 - 0 - 1
Change Category:
Correction
Change Impact:
Compatible, substantive

Notes from Da Vinci PDex meeting

Deductible - could be zero or could have a maintenance drug that is covered before the deductible, but others go through the deductible.
Value that is missing is a charge value - drug not subject to deductible, but there is a deductible otherwise. (not free, but not subject to deductible)
- "Charge" isn't clear - so something like "excluded from deductible" or "outside of.."
- "not subject to deductible" - people liked this.
Let's harmonize with the EOB.
This is in the drug tier definition extension.
Two uses: co-pay and co-insurance.