<?xml version="1.0" encoding="UTF-8"?>

<Coverage xmlns="http://hl7.org/fhir">
  <id value="7546D"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the coverage</div>
  </text>
  <identifier>
    <system value="http://xyz.com/codes/identifier"/>
    <value value="AB98761"/>
  </identifier>
  <status value="active"/>
  <kind value="insurance"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <code value="EHCPOL"/>
      <display value="extended healthcare"/>
    </coding>
  </type>
  <subscriber>
    <reference value="Patient/5"/>
  </subscriber>
  <subscriberId>
    <value value="AB9876"/>
  </subscriberId>
  <beneficiary>
    <reference value="Patient/5"/>
  </beneficiary>
  <dependent value="1"/>
  <relationship>
    <coding>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2011-03-17"/>
    <end value="2012-03-17"/>
  </period>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
    </type>
    <value>
      <value value="WESTAIR"/>
    </value>
    <name value="Western Airlines"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
      </coding>
    </type>
    <value>
      <value value="BG4352"/>
    </value>
    <name value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subplan"/>
      </coding>
    </type>
    <value>
      <value value="D15C9"/>
    </value>
    <name value="Platinum"/>
  </class>
  <order value="2"/>
  <!--  Second after the national medical coverage  -->
  <network value="5"/>
  <costToBeneficiary>
    <type>
      <!--  normally $40.00  -->
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
        <code value="gpvisit"/>
      </coding>
    </type>
    <valueMoney>
      <value value="20.00"/>
      <currency value="USD"/>
    </valueMoney>
    <exception>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception"/>
          <code value="retired"/>
        </coding>
      </type>
      <period>
        <start value="2018-01-01"/>
        <end value="2018-12-31"/>
      </period>
    </exception>
  </costToBeneficiary>
  <contract>
    <reference value="Contract/INS-101"/>
  </contract>
</Coverage>