{
  "resourceType" : "Coverage",
  "id" : "Example-Coverage1",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-04-06T10:49:02.473+00:00",
    "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Acme Gold Plus</div>"
  },
  "extension" : [{
    "extension" : [{
      "url" : "memberId",
      "valueId" : "102345672-01"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["John"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueId" : "102345672-02"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["Jane"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueId" : "102345672-03"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["Jimmy"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueId" : "102345672-04"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["Ginny"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension",
    "valueAnnotation" : {
      "text" : "If you use a TTY, call 711.\nYou may be asked to present this card when you receive care or fill a perscription. This card does not gaurentee coverage. Intentionally misusing this card may be considered fraud or a violation of the law.\nWe encourage you to use a primary care physician as a valuable resource and personal health advocate."
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension",
    "valueDate" : "2020-12-15"
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#00bfff"
        }]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#000000"
        }]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#ceebf5"
        }]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension"
  },
  {
    "extension" : [{
      "url" : "label",
      "valueString" : "ACME Inc."
    },
    {
      "url" : "description",
      "valueString" : "Company logo"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : "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"
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"
  },
  {
    "extension" : [{
      "url" : "label",
      "valueString" : "Some lable for this QR code"
    },
    {
      "url" : "description",
      "valueString" : "Usage text for this QR code for the end user"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : "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"
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"
  },
  {
    "extension" : [{
      "url" : "label",
      "valueString" : "Some label for this Barcode"
    },
    {
      "url" : "description",
      "valueString" : "Usage text for this Barcode for the end user"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : "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"
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"
  },
  {
    "extension" : [{
      "url" : "label",
      "valueString" : "Some label text"
    },
    {
      "url" : "description",
      "valueString" : "Some text for the end user about the usage/meaning of this image"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : "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"
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"
  }],
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
        "code" : "MB",
        "display" : "Member Number"
      }]
    },
    "system" : "https://www.acmeinsurance.com/glossary/memberid",
    "value" : "102345672-02",
    "assigner" : {
      "display" : "Acme Insurance Co"
    }
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
      "code" : "HIP",
      "display" : "health insurance plan policy"
    }],
    "text" : "health insurance plan policy"
  },
  "subscriber" : {
    "reference" : "Patient/Example-Patient1",
    "display" : "John Doe"
  },
  "subscriberId" : "102345672-01",
  "beneficiary" : {
    "reference" : "Patient/Example-Patient2",
    "display" : "Jane Doe"
  },
  "dependent" : "02",
  "relationship" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
      "code" : "spouse",
      "display" : "Spouse"
    }],
    "text" : "Spouse"
  },
  "period" : {
    "start" : "2021-01-01"
  },
  "payor" : [{
    "reference" : "Organization/Example-PayerOrganization1",
    "display" : "Acme Insurance Co"
  }],
  "class" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "group"
      }]
    },
    "value" : "993355",
    "name" : "Stars Inc"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "plan"
      }]
    },
    "value" : "11461128",
    "name" : "Acme Gold Plus"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
        "code" : "division"
      }]
    },
    "value" : "11"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
        "code" : "network"
      }]
    },
    "value" : "561490",
    "name" : "Acme Gold Plus South"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "rxbin"
      }]
    },
    "value" : "100045"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "rxpcn"
      }]
    },
    "value" : "1234000"
  }],
  "costToBeneficiary" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamOutDed",
        "display" : "Family Out of Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 10000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamInDed",
        "display" : "Family In Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 8000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxOutDed",
        "display" : "Family Pharmacy Out of Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 2000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxInDed",
        "display" : "Family Pharmacy In Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 1500.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamOutMax",
        "display" : "Family Out of Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 12000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamInMax",
        "display" : "Family In Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 10000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxOutMax",
        "display" : "Family Pharmacy Out of Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 3000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxInMax",
        "display" : "Family Pharmacy In Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 2000.00,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
        "code" : "gpvisit"
      }]
    },
    "valueMoney" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
        "valueString" : "N/A"
      }]
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
        "code" : "spvisit"
      }]
    },
    "valueMoney" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
        "valueString" : "N/A"
      }]
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
        "code" : "emergency"
      }]
    },
    "valueMoney" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
        "valueString" : "N/A"
      }]
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "rx"
      }]
    },
    "valueMoney" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
        "valueString" : "DED THEN $10/$40/$70/25%"
      }]
    }
  }]
}