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  1. FHIR Specification Feedback
  2. FHIR-37717

Add guidance for granular pharmacy benefits

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    • Change Request
    • Status: Resolved - change required (View Workflow)
    • Medium
    • Resolution: Persuasive
    • US Da Vinci Drug Formulary (FHIR)
    • 1.2.0
    • Pharmacy
    • Formulary Drug
      Formulary Item
    • Hide

      Add the following guidance under the Use cases and overview page under the Additional Guidance section (as the first section).

      Specific Drug Coverage Details

      RxNorm codes and descriptions were chosen as the mechanism for searching and describing covered drugs for consumer use because that is what consumers will generally have access to given the requirements laid out in US regulation. RxNorm is also the code system used for many outpatient pharmacy prescribing transactions.

      RxNorm provides a consumer accessible categorization for prescribable drugs. This categorization may not be specific enough for payers that have very detailed coverage constraints they feel are necessary to express to their members.

      This IG Provides the following ways to express various levels of coverage (coverage status, requirements, or costs) for multiple drugs represented under one RxNorm code.

      • Specific drugs identified by unique FormularyDrug resource instances that are  associated to a Formulary with specific coverage conditions, requirements, and costs through a FormularyItem.
        • A specific drug code using NDC or other code system is included as a FormularyDrug MedicationKnowledge.code.coding that includes the specific name in the display to enable searching.
      • Drugs identified by a general RxNorm code in a single FormularyDrug MedicationKnowledge resource with specific coverage conditions and requirements communicated in the referenced FormularyItem.
        • Specific details including drugs covered or not covered, coverage conditions, or requirements are specified in the FormularyItem Basic.extensions[usdf-AdditionalCoverageInformation-extension].

       

      To the Searching Formulary Drugs section, at the bottom of the main section add:

      Note: In addition to the guidance and requirements below regarding searching for drugs based on an RxNorm code or display, servers may wish to support additional coding systems and display values in order to represent specific drugs that may have the same RxNorm code, but have different coverage specifics as defined in [Specific DrugCoverage Details](specific-drug-coverage-details). This may result in more than one [FormularyDrug]( StructureDefinition-usdf-FormularyDrug.html) with the same RxNorm code and display value.

      Show
      Add the following guidance under the Use cases and overview page under the Additional Guidance section (as the first section). Specific Drug Coverage Details RxNorm codes and descriptions were chosen as the mechanism for searching and describing covered drugs for consumer use because that is what consumers will generally have access to given the requirements laid out in US regulation. RxNorm is also the code system used for many outpatient pharmacy prescribing transactions. RxNorm provides a consumer accessible categorization for prescribable drugs. This categorization may not be specific enough for payers that have very detailed coverage constraints they feel are necessary to express to their members. This IG Provides the following ways to express various levels of coverage (coverage status, requirements, or costs) for multiple drugs represented under one RxNorm code. Specific drugs identified by unique  FormularyDrug  resource instances that are  associated to a Formulary with specific coverage conditions, requirements, and costs through a  FormularyItem . A specific drug code using NDC or other code system is included as a  FormularyDrug  MedicationKnowledge.code.coding that includes the specific name in the display to enable searching. Drugs identified by a general RxNorm code in a single  FormularyDrug  MedicationKnowledge resource with specific coverage conditions and requirements communicated in the referenced  FormularyItem. Specific details including drugs covered or not covered, coverage conditions, or requirements are specified in the  FormularyItem  Basic.extensions [usdf-AdditionalCoverageInformation-extension] .   To the Searching Formulary Drugs section, at the bottom of the main section add: Note: In addition to the guidance and requirements below regarding searching for drugs based on an RxNorm code or display, servers may wish to support additional coding systems and display values in order to represent specific drugs that may have the same RxNorm code, but have different coverage specifics as defined in [Specific DrugCoverage Details] (specific-drug-coverage-details). This may result in more than one [FormularyDrug] ( StructureDefinition-usdf-FormularyDrug.html) with the same RxNorm code and display value.
    • Corey Spears / Peter Sergent : 7-0-0
    • Clarification
    • Non-substantive

    Description

      Multiple drugs covered under a single RxNorm code (as defined by the IG) may have differing levels of coverage (coverage status, requirements, or costs). This may include manufacturer, form (elixir vs solution), and other factors. 

      Payers may determine that the specific drugs and coverage details need to be expressed to the member.

      Suggest adding the following guidance under the Use cases and overview page under the Additional Guidance section (as the first section).

      Specific Drug Coverage Details

      RxNorm codes and descriptions were chosen as the mechanism for searching and describing covered drugs for consumer use because that is what consumers will generally have access to given the requirements laid out in US regulation. RxNorm is also the code system used for many outpatient pharmacy prescribing transactions.

      RxNorm provides a consumer accessible categorization for prescribable drugs. This categorization may not be specific enough for payers that have very detailed coverage constraints they feel are necessary to express to their members.

      This IG Provides the following ways to express various levels of coverage (coverage status, requirements, or costs) for multiple drugs represented under one RxNorm code.

      1. Specific drugs identified by unique FormularyDrug resource instances that are  associated to a Formulary with specific coverage conditions, requirements, and costs through a FormularyItem.
        1. A specific drug code using NDC or other code system is included as a FormularyDrug MedicationKnowledge.code.coding that includes the specific name in the display to enable searching.
      2. Drugs identified by a general RxNorm code in a single FormularyDrug MedicationKnowledge resource with specific coverage conditions and requirements communicated in the referenced FormularyItem
        1. Specific details including drugs covered or not covered, coverage conditions, or requirements are specified in the FormularyItem Basic.extensions[usdf-AdditionalCoverageInformation-extension]

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