2021-05-14 PDex Meeting

2021-05 Da Vinci Payer Data Exchange Track for CMS Patient Access API

See Whova for Kick Off recording from 05/07/2021 at 5:30 PM GMT (1:30pm ET)

Working toward getting one Patient data setup on one server setup for a cohesive Patient Access API across PDex, Carin BB, Formulary, 

Useful links: 

1) Get access to Test Scripts publicly available will be used as basis for testing during event. See Recording - TouchStone Overview and/or reach out to touchstone_support@aegis.net if you have any follow on needed for helping with testing setup

2) Add your servers here Connectathon Test Servers -

3) Set setup in ConMan: http://conman.clinfhir.com/connectathon.html?event=con27 - Get your environment setup and ready to connect before the event so you can use the event to test, rather than setup.  

4) Read the IG

Any questions?  

Discussion on: https://chat.fhir.org/#narrow/stream/197730-Da-Vinci.20PDex.20Drug.20Formulary/topic/Copay.20.26.20Coinsurance

Like the ability to say 100% copay and then after the deductible is met, I want to say either 100% or flat co-pay after deductible. 

Note: NCPDP path - you can define it all. 

You can have multiple cost sharing with the ..* so can specify before and after deductible. 

Discussion around if this should be an ordered list to avoid additional confusion for the  users for after deductible information when they aren't there yet. 

Add comment in Zulip for what order you'd like to see things in.  Right now, there is no requirement for ordering.  It's a nice to have.

The N/A option is helpful.  Since co-insurance is mandatory. 

Next Step: Add $X (or "Charge" or "Shared Cost" to be more agnostic beyond USD) and Not Applicable values to co-insurance.

Another Issue: 

• https://chat.fhir.org/#narrow/stream/197730-Da-Vinci.20PDex.20Drug.20Formulary/topic/Not.20Covered.20Drugs 

• Want a distinction between:
  • non-formulary - The implementer even has a delineation of non-formulary with and without Prior Auth. (Covered in the guide with the PA Flag)
  • non-covered
  • not found
• Non-formulary drugs could have some coverage.  Not including a non-formulary drug in formulary is expected behavior, but if they have more detailed information about why, they'd like a place to provider that information to the use.  i.e. prove the null result set to inform the user why it's not on their formulary.  Important to express this difference to the user.  
• Talked about Fuzzy logic search option - e.g. typo in name of drug - 
  • Standard Search parameter defines what they search is (it's not the distinct search)
• Certain classes or drugs or excluded for certain patients (i.e. Viagra; - yes we know about the drug, but it's not covered)
• Simpler approach may be: if the search parameter 
  • No matches, by the way - no drugs by that name. 
  • Should or shall - operational outcome could include the info for the user.
  • Server would have cull copy of RXNorm; but the light weight ... won't. 
  • IG could say "you should have a query into the RxNorm set so you know if the drug exists or not." outside of the Formulary query.

Do we need a coverage plan for every formulary drug.

Formulary Ticket updates

PDex Formulary JIRA Tracker Dashboard

Examples from chat:  Insulins, anti-cancer, sometimes whole drug tiers may not be subject to deductible.

Implementer Support

Review FAQ Proposed Responses  

See you next week (5/21.)  Cancel call on 5/28/21 due to WGM.

PDex IG Companion Guide List

PDex IG Companion Guide - Laboratory Reporting Resources

Latest draft CARIN CPCDS Mapping document: CARIN Mapping to FHIR interim 2020 0818 v2.xlsx

DRAFT - PDEX US Core Mapping from CPCDS source: ResourceMappingUSCoreCPCDS-2020-05-29-v26.xlsx

Find initial questions and corresponding answers shared from our colleagues at CMS here

• Links to Published IGs

• PDex STU 1.0.0
• Plan Net STU 1.0.0
• Formulary - STU 1.0.1