Stream: Da Vinci PDex Drug Formulary
Topic: CostSharing Extension
Mark Neumuth (Jan 25 2021 at 21:56):
@Dave Hill @Robert Dieterle One of the questions we didn't get to during Friday's PDex call was regarding the CostSharing Extension. The available selections for CopayOption and CoinsuranceOption don't seem to fit if the Medicaid Plan has a deductible of $0. All of these would mislead the member if there is no deductible:
after-deductible
before-deductible
no-charge
no-charge-after-deductible
Is there something we're missing? We can use "after-deductible" for now but recommend adding another selection that is specific to this situation for the next build. What are your thoughts? @Courtney Bland @Vanessa Candelora
Saul Kravitz (Jan 27 2021 at 16:27):
The structure/definition of the cost sharing extensions were (rightly or wrongly) based on the QHP Formulary -- see https://github.com/CMSgov/QHP-provider-formulary-APIs#cost-sharing-sub-type.
image.png
The QHP Formulary definition is a bit thin on how to actually use the fields.
Looking at the 2021 instructions for registering a QHP formulary (see https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/QHP_Slides_040220_5CR_040220_8.pdf, starting at slide 21) there is a bit more detail.
1) There is an additional value of "Not Applicable" for both the CopayOption and the CoInsuranceOption.
2) There is a plan-level text field for any explanation of features that don't fit well into the structure.
3) Zero-Cost Drugs, two options are presented:
- CoPaymentOption: N/A, CoInsuranceOption: No Charge, or
- CoPaymentOptiion: No Charge, CoInsuranceOption: N/A
4) Business rule says you can't specify N/A for both CoPaymentOption and CoInsuranceOption
Seems like we are missing the N/A values for both CopaymentOption and CoinsuranceOption, and some guidance on how to handle some of the expected corner cases.
Mark Neumuth (Feb 04 2021 at 13:54):
Thanks Saul! Can the next version of the Formulary IG include values of "N/A" for CopayOption and CoinsuranceOption? Though the business rule of not having both N/A would not apply since not having Copay and Coinsurance is a possibility with some Medicaid plans.
Saul Kravitz (Feb 04 2021 at 17:15):
https://jira.hl7.org/browse/FHIR-30924
Last updated: Apr 12 2022 at 19:14 UTC
