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

## : Coverage Example 1 - 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:Coverage ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "Example-Coverage1"] ; #
      fhir:meta [
    fhir:versionId [ fhir:v "1" ] ;
    fhir:lastUpdated [ fhir:v "2021-04-06T10:49:02.473+00:00"^^xsd:dateTime ] ;
        ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\">Acme Gold Plus</div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "memberId"^^xsd:anyURI ;
    fhir:l fhir:memberId       ] ;
    fhir:value [
    a fhir:Id ;
    fhir:v "102345672-01"       ]     ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:HumanName ;
    fhir:family [ fhir:v "Doe" ] ;
            ( fhir:given [ fhir:v "John" ] )       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "memberId"^^xsd:anyURI ;
    fhir:l fhir:memberId       ] ;
    fhir:value [
    a fhir:Id ;
    fhir:v "102345672-02"       ]     ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:HumanName ;
    fhir:family [ fhir:v "Doe" ] ;
            ( fhir:given [ fhir:v "Jane" ] )       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "memberId"^^xsd:anyURI ;
    fhir:l fhir:memberId       ] ;
    fhir:value [
    a fhir:Id ;
    fhir:v "102345672-03"       ]     ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:HumanName ;
    fhir:family [ fhir:v "Doe" ] ;
            ( fhir:given [ fhir:v "Jimmy" ] )       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "memberId"^^xsd:anyURI ;
    fhir:l fhir:memberId       ] ;
    fhir:value [
    a fhir:Id ;
    fhir:v "102345672-04"       ]     ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:HumanName ;
    fhir:family [ fhir:v "Doe" ] ;
            ( fhir:given [ fhir:v "Ginny" ] )       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension>     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension>     ] ;
    fhir:value [
    a fhir:Annotation ;
    fhir:text [ fhir:v "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." ]     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension>     ] ;
    fhir:value [
    a fhir:Date ;
    fhir:v "2020-12-15"^^xsd:date     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension>       ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/IECColourManagement>           ] ;
    fhir:code [ fhir:v "#00bfff" ]         ] )       ]     ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension>       ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/IECColourManagement>           ] ;
    fhir:code [ fhir:v "#000000" ]         ] )       ]     ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension>       ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/IECColourManagement>           ] ;
    fhir:code [ fhir:v "#ceebf5" ]         ] )       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "ACME Inc."       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Company logo"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/png" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some lable for this QR code"       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Usage text for this QR code for the end user"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/png" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some label for this Barcode"       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Usage text for this Barcode for the end user"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/png" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some label text"       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some text for the end user about the usage/meaning of this image"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/png" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension>     ]
      ] ) ; #
      fhir:identifier ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v2-0203>         ] ;
    fhir:code [ fhir:v "MB" ] ;
    fhir:display [ fhir:v "Member Number" ]       ] )     ] ;
    fhir:system [
    fhir:v "https://www.acmeinsurance.com/glossary/memberid"^^xsd:anyURI ;
    fhir:l <https://www.acmeinsurance.com/glossary/memberid>     ] ;
    fhir:value [ fhir:v "102345672-02" ] ;
    fhir:assigner [
    fhir:display [ fhir:v "Acme Insurance Co" ]     ]
      ] ) ; #
      fhir:status [ fhir:v "active"] ; #
      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:text [ fhir:v "health insurance plan policy" ]
      ] ; #
      fhir:subscriber [
    fhir:l fhir:Patient/Example-Patient1 ;
    fhir:reference [ fhir:v "Patient/Example-Patient1" ] ;
    fhir:display [ fhir:v "John Doe" ]
      ] ; #
      fhir:subscriberId [ fhir:v "102345672-01"] ; #
      fhir:beneficiary [
    fhir:l fhir:Patient/Example-Patient2 ;
    fhir:reference [ fhir:v "Patient/Example-Patient2" ] ;
    fhir:display [ fhir:v "Jane Doe" ]
      ] ; #
      fhir:dependent [ fhir:v "02"] ; #
      fhir:relationship [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/subscriber-relationship"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/subscriber-relationship>       ] ;
    fhir:code [ fhir:v "spouse" ] ;
    fhir:display [ fhir:v "Spouse" ]     ] ) ;
    fhir:text [ fhir:v "Spouse" ]
      ] ; #
      fhir:period [
    fhir:start [ fhir:v "2021-01-01"^^xsd:date ]
      ] ; #
      fhir:payor ( [
    fhir:l fhir:Organization/Example-PayerOrganization1 ;
    fhir:reference [ fhir:v "Organization/Example-PayerOrganization1" ] ;
    fhir:display [ fhir:v "Acme Insurance Co" ]
      ] ) ; #
      fhir:class ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-class>         ] ;
    fhir:code [ fhir:v "group" ]       ] )     ] ;
    fhir:value [ fhir:v "993355" ] ;
    fhir:name [ fhir:v "Stars Inc" ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-class>         ] ;
    fhir:code [ fhir:v "plan" ]       ] )     ] ;
    fhir:value [ fhir:v "11461128" ] ;
    fhir:name [ fhir:v "Acme Gold Plus" ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS>         ] ;
    fhir:code [ fhir:v "division" ]       ] )     ] ;
    fhir:value [ fhir:v "11" ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS>         ] ;
    fhir:code [ fhir:v "network" ]       ] )     ] ;
    fhir:value [ fhir:v "561490" ] ;
    fhir:name [ fhir:v "Acme Gold Plus South" ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-class>         ] ;
    fhir:code [ fhir:v "rxbin" ]       ] )     ] ;
    fhir:value [ fhir:v "100045" ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-class>         ] ;
    fhir:code [ fhir:v "rxpcn" ]       ] )     ] ;
    fhir:value [ fhir:v "1234000" ]
      ] ) ; #
      fhir:costToBeneficiary ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamOutDed" ] ;
    fhir:display [ fhir:v "Family Out of Network Deductible" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 10000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamInDed" ] ;
    fhir:display [ fhir:v "Family In Network Deductible" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 8000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamRxOutDed" ] ;
    fhir:display [ fhir:v "Family Pharmacy Out of Network Deductible" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 2000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamRxInDed" ] ;
    fhir:display [ fhir:v "Family Pharmacy In Network Deductible" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 1500.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamOutMax" ] ;
    fhir:display [ fhir:v "Family Out of Network Out of Pocket Maximum" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 12000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamInMax" ] ;
    fhir:display [ fhir:v "Family In Network Out of Pocket Maximum" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 10000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamRxOutMax" ] ;
    fhir:display [ fhir:v "Family Pharmacy Out of Network Out of Pocket Maximum" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 3000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "FamRxInMax" ] ;
    fhir:display [ fhir:v "Family Pharmacy In Network Out of Pocket Maximum" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v 2000.00 ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-copay-type>         ] ;
    fhir:code [ fhir:v "gpvisit" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "N/A"         ]       ] )     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-copay-type>         ] ;
    fhir:code [ fhir:v "spvisit" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "N/A"         ]       ] )     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/coverage-copay-type>         ] ;
    fhir:code [ fhir:v "emergency" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "N/A"         ]       ] )     ]
      ] [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS>         ] ;
    fhir:code [ fhir:v "rx" ]       ] )     ] ;
    fhir:value [
    a fhir:Money ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension>         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "DED THEN $10/$40/$70/25%"         ]       ] )     ]
      ] ) . #