<Claim xmlns="http://hl7.org/fhir"><id value="760152"/><text><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Pharmacy Claim</div></text><identifier><system value="http://happypharma.com/claim"/><value value="7612345"/></identifier><status value="active"/><type><coding><system value="http://terminology.hl7.org/CodeSystem/claim-type"/><code value="pharmacy"/></coding></type><use value="claim"/><subject><reference value="Patient/1"/></subject><created value="2014-08-16"/><insurer><reference value="Organization/2"/></insurer><provider><reference value="Organization/1"/></provider><priority><coding><code value="stat"/></coding></priority><payee><type><coding><code value="provider"/></coding></type></payee><careTeam><sequence value="1"/><provider><reference value="Practitioner/example"/></provider></careTeam><supportingInfo><sequence value="1"/><category><coding><code value="pharmacyrefill"/></coding></category><code><coding><system value="http://example.org/fhir/CodeSystem/pharmacy-refill"/><code value="new"/></coding></code></supportingInfo><supportingInfo><sequence value="2"/><category><coding><code value="pharmacyinformation"/></coding></category><code><coding><system value="http://example.org/fhir/CodeSystem/pharmacy-information"/><code value="refillsremaining"/></coding></code><valueQuantity><value value="0"/></valueQuantity></supportingInfo><supportingInfo><sequence value="3"/><category><coding><code value="pharmacyinformation"/></coding></category><code><coding><system value="http://example.org/fhir/CodeSystem/pharmacy-information"/><code value="dayssupply"/></coding></code><valueQuantity><value value="10"/></valueQuantity></supportingInfo><supportingInfo><sequence value="4"/><category><coding><code value="pharmacy"/></coding></category><code><coding><system value="http://example.org/fhir/CodeSystem/pharmacy-form"/><code value="capsule"/></coding></code></supportingInfo><diagnosis><sequence value="1"/><diagnosisCodeableConcept><coding><code value="654456"/></coding></diagnosisCodeableConcept></diagnosis><insurance><sequence value="1"/><focal value="true"/><coverage><reference value="Coverage/9876B1"/></coverage></insurance><item><sequence value="1"/><careTeamSequence value="1"/><informationSequence value="1"/><informationSequence value="2"/><informationSequence value="3"/><informationSequence value="4"/><productOrService><coding><system value="http://localdruglist.org"/><code value="compound"/><display value="Custom compound"/></coding></productOrService><servicedDate value="2014-08-16"/><quantity><value value="30"/><unit value="TAB"/><system value="http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/><code value="TAB"/></quantity><net><value value="155.00"/><currency value="USD"/></net><detail><sequence value="1"/><productOrService><coding><system value="http://localdruglist.org"/><code value="44001"/><display value="Acetaminophen 250mg"/></coding></productOrService><quantity><value value="250"/><unit value="mg"/></quantity><net><value value="20.00"/><currency value="USD"/></net><subDetail><sequence value="1"/><productOrService><coding><system value="http://hl7.org/fhir/ex-pharmaservice"/><code value="drugcost"/></coding></productOrService><net><value value="20.00"/><currency value="USD"/></net></subDetail></detail><detail><sequence value="2"/><productOrService><coding><system value="http://localdruglist.org"/><code value="44035"/><display value="Phenacetin 50mg"/></coding></productOrService><quantity><value value="50"/><unit value="mg"/></quantity><net><value value="25.00"/><currency value="USD"/></net><subDetail><sequence value="1"/><productOrService><coding><system value="http://hl7.org/fhir/ex-pharmaservice"/><code value="drugcost"/></coding></productOrService><net><value value="25.00"/><currency value="USD"/></net></subDetail></detail><detail><sequence value="3"/><productOrService><coding><system value="http://localdruglist.org"/><code value="44057"/><display value="Codeine 25mg"/></coding></productOrService><quantity><value value="25"/><unit value="mg"/></quantity><net><value value="28.00"/><currency value="USD"/></net><subDetail><sequence value="1"/><productOrService><coding><system value="http://hl7.org/fhir/ex-pharmaservice"/><code value="drugcost"/></coding></productOrService><net><value value="28.00"/><currency value="USD"/></net></subDetail></detail><detail><sequence value="2"/><productOrService><coding><system value="http://hl7.org/fhir/ex-pharmaservice"/><code value="markup"/></coding></productOrService><net><value value="22.00"/><currency value="USD"/></net></detail><detail><sequence value="3"/><productOrService><coding><system value="http://hl7.org/fhir/ex-pharmaservice"/><code value="compoundfee"/></coding></productOrService><net><value value="60.00"/><currency value="USD"/></net></detail></item><total><value value="155.00"/><currency value="USD"/></total></Claim>