Stream: Da Vinci PDex Drug Formulary
Topic: Copay & Coinsurance
Ankita Srivastava (Apr 29 2021 at 13:44):
Hello Team,
https://davinci-drug-formulary-ri.logicahealth.org/fhir/MedicationKnowledge?_profile=http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/usdf-FormularyDrug
returns list of Formulary Drugs with Tier, Copay & Coinsurance columns
However, each Drug Tier can have multiple cost-sharing based on Pharmacy Type which can result in multiple copay & coinsurance.
So which Copay & Coinsurance we need to display under Formulary Drug?
Kindly help.
Thanks
Ankita Srivastava (Apr 29 2021 at 13:46):
Corey Spears (May 03 2021 at 23:06):
This seems like an application design choice. The Reference Implementation just chose one to display as an example. Your application may want to provide a way to filter, choose, or display the options. This will depend on the needs of your users.
Ankita Srivastava (May 04 2021 at 06:08):
Thank you so much @Corey Spears for the response. It is helpful.
Bruce Wilkinson (May 12 2021 at 21:36):
Along this topic, I have a question on accurate copay support. Looking at the example for v3002, specifically 1st costSharing segment for 1-month-in-retail, I read it as (which seems backward):
- $10 copay before deductible
- 100% coinsurance after deductible
Is this an accurate reading or it is it trying to represent a $10 copay after a 100% before deductible coinsurance?
It's great to show both the before and after deductible copays without doing two costSharing segments for 1-month-in-retail but, if my reading above is correct, how do I format FHIR to say (for these two use cases):
- 100% coinsurance before deductible
- $10 copay after deductible has been met
and
- 100% coinsurance before deductible
- 15% coinsurance after deductible has been met
Outside of prevention tier, most of our plans have a 100% deductible then a flat or % copay. What is the best way to support 100% copay before deductible with a $10 copay/15% coinsurance after deductible via PDex? Thanks.
reference
http://hl7.org/fhir/us/davinci-drug-formulary/STU1.0.1/List-CoveragePlanV3002.html
"extension" : [
{
"url" : "drugTierID",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-DrugTierCS",
"code" : "generic",
"display" : "Generic: Commonly prescribed generic drugs that cost more than drugs in the ‘preferred generic’ tier."
}
]
}
},
{
"url" : "mailOrder",
"valueBoolean" : true
},
{
"extension" : [
{
"url" : "pharmacyType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-PharmacyTypeCS",
"code" : "1-month-in-retail",
"display" : "1 month in network retail: 1 Month Supply via in-network retail pharmacy."
}
]
}
},
{
"url" : "copayAmount",
"valueMoney" : {
"value" : 10
}
},
{
"url" : "copayOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS",
"code" : "before-deductible",
"display" : "Before Deductible: The consumer first pays the copay, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible)."
}
]
}
},
{
"url" : "coinsuranceRate",
"valueDecimal" : 1
},
{
"url" : "coinsuranceOption",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CoinsuranceOptionCS",
"code" : "after-deductible",
"display" : "After Deductible: The consumer first pays the deductible, and after the deductible is met, the consumer pays the coinsurance portion of allowed charges (this indicates that this benefit is subject to the deductible)."
}
]
}
}
],
Thanks in advance for any help. I may be missing something here since expect that what I want to do should be supported.
Mark Scrimshire (May 14 2021 at 16:39):
https://www.qhpcertification.cms.gov/s/FINALPY2021_QHPApplicationInstructions.pdf?v=1 Page 56
Mona O (Jun 11 2021 at 12:14):
@Saul Kravitz , It was recently brought to our attention that our representation of coinsuranceRate is not being represented accurately as we are utilizing valueDecimal. Our data source is representing the value as a percentage 25.00 instead of the true decimal representation of 0.25. We have multiple subscribers already integrated with our API and no one identified this as an issue until recently. Based on the data type being a decimal I believe we are not conformant. Are we indeed not conformant?
Are we able to manage this gap through documentation to indicate the value is represented as a percentage or do we need to get all of our current consumers to make changes once we start representing the value as a decimal? Are there any recommendations on how to approach that?
Saul Kravitz (Jun 11 2021 at 13:06):
@Corey Spears
Corey Spears (Jun 17 2021 at 06:29):
The number does represent a multiplier, and while the spec does not explicitly state how to represent percentages, it is reasonable that this would be interpreted as being a true decimal representation, particularly since units is not expressed. I would expect most might interpret it that way.
I cannot suggest how you might address this issue operationally, but one might document the current behavior while communicating it to trading partners with plans to modify in the future and updating documentation and advanced communications when changes are being made.
Last updated: Apr 12 2022 at 19:14 UTC
