Owning work group name: Pharmacy

Committee Approval Date: January 18, 2022

Contributing or Reviewing Work Groups: None

FHIR Resource Development Project Insight ID: 1239

Scope of coverage:

A FormularyItem is a product or service that is available through a program and includes the conditions and constraints of availability, eg. amount limits, categorization, cost limits, and other requirements for use.  This resource describes the program-specific information for a product or service.  This information is specific to the inclusion of the item in the formulary and is not inherent to the item itself.

This diagram was created for the PDEX US Drug Formulary Implementation Guide but it shows where FormularyItem would fit in a drug context.  If you abstract that to generic Insurance Plans to the left and to a set of resources that can be referenced to the right, that is the concept behind the FormularyItem resource.

RIM scope:  

Role with classCode of MBR (member) or PRT (part) with the playing entity being the referenced resource and the scoping entity being the Formulary.

Resource appropriateness:

There is a need to exchange formulary-specific information about a number of existing FHIR resources.  Rather than embedding the formulary data elements in every FHIR resource, this resource would allow the data elements to be expressed and reference the relevant FHIR resource of which the FormularyItem is describing.

Expected implementations:

Da Vinci Payer Data Exchange US Drug Formulary FHIR Implementation Guide

PHAST Catalogue Project

Content sources: None

Example Scenarios:

A drug plan would be a Formulary and it would have FormularyItems that provided information such as drug tier, quantity limit, pharmacy type, mail order, step therapy limit, prior authorization.

An organization-specific Formulary could include information about costs and restrictions on the use of drugs, lab tests, devices, and procedures.

Resource Relationships:
The following resources would be referenced as the product or service being described in the formulary:

  • MedicationKnowledge (drugs)
  • ObservationDefinition (lab tests)
  • DeviceDefinition (devices)
  • ActivityDefinition (procedures)
  • NutritionProduct
  • BiologicallyDerivedProduct

Composition would reference this resource when it is being used to describe the formulary.

Resource Boundaries:
FormularyItem would provide the data elements that are formulary-specific for the products or services.  The resources that are referenced by the FormularyItem (see Resource Relationships above) would not have any formulary-specific data elements.  Any non-formulary-specific information would be found in the referenced resources and not in the FormularyItem.

Timelines: Ready for May 2022 Balloting

GitHub Users: Current Pharmacy resource committers

When Resource Proposal Is Complete:

When you have completed your proposal, please send an email to FMGcontact@HL7.org

FMG Notes