CARIN Digital Insurance Card
2.0.0 - STU 2.0

CARIN Digital Insurance Card, published by HL7 International / Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-digital-insurance-card/ and changes regularly. See the Directory of published versions

## : Example SBC - Sample HMO Health Plan - TTL Representation

Page standards status: Informative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:InsurancePlan ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "SBCExampleHMO"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan SBCExampleHMO</b></p><a name=\"SBCExampleHMO\"> </a><a name=\"hcSBCExampleHMO\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-sbc-insurance-plan.html\">SBC Insurance Plan Profile</a></p></div><blockquote><p><b>SBC Metadata Extension</b></p><ul><li>sbcVersionDate: 2021-01-01</li><li>minimumEssentialCoverage: true</li><li>minimumValue: true</li></ul></blockquote><blockquote><p><b>Excluded Services Extension</b></p><p><b>serviceType</b>: <span title=\"Codes:\">Cosmetic surgery</span></p><p><b>description</b>: Services for cosmetic purposes are not covered</p><blockquote><p><b>url</b></p>service</blockquote><p><b>serviceType</b>: <span title=\"Codes:\">Weight loss programs</span></p><p><b>description</b>: Weight loss programs except when medically necessary</p><blockquote><p><b>url</b></p>service</blockquote></blockquote><p><b>identifier</b>: <code>https://www.cms.gov/CCIIO/Resources/Data-Resources/hios</code>/12345CA0010001-01</p><p><b>status</b>: Active</p><p><b>name</b>: Sample Health HMO Gold Plan</p><p><b>period</b>: 2025-01-01 --&gt; 2025-12-31</p><p><b>ownedBy</b>: <a href=\"Organization-ExampleIssuerOrg.html\">Sample Health Insurance Company</a></p><p><b>administeredBy</b>: <a href=\"Organization-ExampleIssuerOrg.html\">Organization Sample Health Insurance Company</a></p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">General Questions</span></p><p><b>telecom</b>: ph: 1-800-123-4567, <a href=\"https://www.samplehealth.com\">https://www.samplehealth.com</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Uniform Glossary</span></p><p><b>telecom</b>: <a href=\"https://www.healthcare.gov/sbc-glossary/\">https://www.healthcare.gov/sbc-glossary/</a></p></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><p><b>requirement</b>: No prior authorization required for in-network preventive services</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><p><b>requirement</b>: No referral required</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Limited to network specialists only; out-of-network not covered except in emergencies</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><p><b>requirement</b>: Referral required from primary care physician</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted to hospital</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><p><b>requirement</b>: Prior authorization required for non-emergency admissions</p></blockquote></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type HMO}\">Health Maintenance Organization (HMO)</span></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Individual Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1500</td><td>United States dollar</td></tr></table><p><b>comment</b>: Individual in-network deductible</p></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Family Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>3000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>6000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Family Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>12000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">No charge</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 0 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 25 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 50 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 350 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 350 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category generic-drugs}\">Generic Drugs</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category generic-drugs}\">Generic Drugs</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 10 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Prior authorization required</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 20 %</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 %</p></blockquote></blockquote></blockquote></blockquote></div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "sbcVersionDate"^^xsd:anyURI ;
    fhir:l fhir:sbcVersionDate       ] ;
    fhir:value [
    a fhir:Date ;
    fhir:v "2021-01-01"^^xsd:date       ]     ] [
    fhir:url [
    fhir:v "minimumEssentialCoverage"^^xsd:anyURI ;
    fhir:l fhir:minimumEssentialCoverage       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v true       ]     ] [
    fhir:url [
    fhir:v "minimumValue"^^xsd:anyURI ;
    fhir:l fhir:minimumValue       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v true       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata>     ]
      ] [
        ( fhir:extension [
          ( fhir:extension [
    fhir:url [
    fhir:v "serviceType"^^xsd:anyURI ;
    fhir:l fhir:serviceType         ] ;
    fhir:value [
    a fhir:CodeableConcept ;
    fhir:text [ fhir:v "Cosmetic surgery" ]         ]       ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Services for cosmetic purposes are not covered"         ]       ] ) ;
    fhir:url [
    fhir:v "service"^^xsd:anyURI ;
    fhir:l fhir:service       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "serviceType"^^xsd:anyURI ;
    fhir:l fhir:serviceType         ] ;
    fhir:value [
    a fhir:CodeableConcept ;
    fhir:text [ fhir:v "Weight loss programs" ]         ]       ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Weight loss programs except when medically necessary"         ]       ] ) ;
    fhir:url [
    fhir:v "service"^^xsd:anyURI ;
    fhir:l fhir:service       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services>     ]
      ] ) ; #
      fhir:identifier ( [
    fhir:system [
    fhir:v "https://www.cms.gov/CCIIO/Resources/Data-Resources/hios"^^xsd:anyURI ;
    fhir:l <https://www.cms.gov/CCIIO/Resources/Data-Resources/hios>     ] ;
    fhir:value [ fhir:v "12345CA0010001-01" ]
      ] ) ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:name [ fhir:v "Sample Health HMO Gold Plan"] ; #
      fhir:period [
    fhir:start [ fhir:v "2025-01-01"^^xsd:date ] ;
    fhir:end [ fhir:v "2025-12-31"^^xsd:date ]
      ] ; #
      fhir:ownedBy [
    fhir:l fhir:Organization/ExampleIssuerOrg ;
    fhir:reference [ fhir:v "Organization/ExampleIssuerOrg" ] ;
    fhir:display [ fhir:v "Sample Health Insurance Company" ]
      ] ; #
      fhir:administeredBy [
    fhir:l fhir:Organization/ExampleIssuerOrg ;
    fhir:reference [ fhir:v "Organization/ExampleIssuerOrg" ]
      ] ; #
      fhir:contact ( [
    fhir:purpose [
    fhir:text [ fhir:v "General Questions" ]     ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "phone" ] ;
    fhir:value [ fhir:v "1-800-123-4567" ]     ] [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "https://www.samplehealth.com" ]     ] )
      ] [
    fhir:purpose [
    fhir:text [ fhir:v "Uniform Glossary" ]     ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "https://www.healthcare.gov/sbc-glossary/" ]     ] )
      ] ) ; #
      fhir:coverage ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v3-ActCode>         ] ;
    fhir:code [ fhir:v "HIP" ] ;
    fhir:display [ fhir:v "health insurance plan policy" ]       ] )     ] ;
        ( fhir:benefit [
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "preventive-care" ]         ] )       ] ;
    fhir:requirement [ fhir:v "No prior authorization required for in-network preventive services" ]     ] [
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "primary-care-visit" ]         ] )       ] ;
    fhir:requirement [ fhir:v "No referral required" ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Limited to network specialists only; out-of-network not covered except in emergencies"         ]       ] ) ;
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "specialist-visit" ]         ] )       ] ;
    fhir:requirement [ fhir:v "Referral required from primary care physician" ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Copay waived if admitted to hospital"         ]       ] ) ;
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "emergency-room-care" ]         ] )       ]     ] [
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "hospital-inpatient" ]         ] )       ] ;
    fhir:requirement [ fhir:v "Prior authorization required for non-emergency admissions" ]     ] )
      ] ) ; #
      fhir:plan ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type>         ] ;
    fhir:code [ fhir:v "HMO" ]       ] )     ] ;
        ( fhir:generalCost [
    fhir:type [
    fhir:text [ fhir:v "Individual Deductible" ]       ] ;
    fhir:cost [
    fhir:value [ fhir:v "1500"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ] ;
    fhir:comment [ fhir:v "Individual in-network deductible" ]     ] [
    fhir:type [
    fhir:text [ fhir:v "Family Deductible" ]       ] ;
    fhir:cost [
    fhir:value [ fhir:v "3000"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ]     ] [
    fhir:type [
    fhir:text [ fhir:v "Individual Out-of-Pocket Maximum" ]       ] ;
    fhir:cost [
    fhir:value [ fhir:v "6000"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ]     ] [
    fhir:type [
    fhir:text [ fhir:v "Family Out-of-Pocket Maximum" ]       ] ;
    fhir:cost [
    fhir:value [ fhir:v "12000"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ]     ] ) ;
        ( fhir:specificCost [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "preventive-care" ]         ] )       ] ;
          ( fhir:benefit [
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "preventive-care" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "No charge" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Not covered" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] )       ] )     ] [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "primary-care-visit" ]         ] )       ] ;
          ( fhir:benefit [
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "primary-care-visit" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "Copayment" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "25"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Not covered" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] )       ] )     ] [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "specialist-visit" ]         ] )       ] ;
          ( fhir:benefit [
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "specialist-visit" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "Copayment" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "50"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Not covered" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] )       ] )     ] [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "emergency-room-care" ]         ] )       ] ;
          ( fhir:benefit [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation>           ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Copay waived if admitted"           ]         ] ) ;
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "emergency-room-care" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "Copayment" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "350"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Copayment" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "350"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] )       ] )     ] [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "generic-drugs" ]         ] )       ] ;
          ( fhir:benefit [
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "generic-drugs" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "Copayment" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "10"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Not covered" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "USD" ]           ]         ] )       ] )     ] [
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>           ] ;
    fhir:code [ fhir:v "hospital-inpatient" ]         ] )       ] ;
          ( fhir:benefit [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation>           ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Prior authorization required"           ]         ] ) ;
    fhir:type [
              ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category>             ] ;
    fhir:code [ fhir:v "hospital-inpatient" ]           ] )         ] ;
            ( fhir:cost [
    fhir:type [
    fhir:text [ fhir:v "Coinsurance" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "in-network" ] ;
    fhir:display [ fhir:v "In Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "20"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "%" ]           ]         ] [
    fhir:type [
    fhir:text [ fhir:v "Not covered" ]           ] ;
    fhir:applicability [
                ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/applicability>               ] ;
    fhir:code [ fhir:v "out-of-network" ] ;
    fhir:display [ fhir:v "Out of Network" ]             ] )           ] ;
    fhir:value [
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "%" ]           ]         ] )       ] )     ] )
      ] ) . #