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-Coverage-FSH - 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-Coverage-FSH"] ; #
      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 "extensions" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Coverage Example-Coverage-FSH</b></p><a name=\"Example-Coverage-FSH\"> </a><a name=\"hcExample-Coverage-FSH\"> </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\">version: 1; Last updated: 2021-04-06 10:49:02+0000</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4DIC-Coverage.html\">C4DIC Coverage</a></p></div><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-01</li><li>name: John Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-02</li><li>name: jane Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-03</li><li>name: Jimmy Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-04</li><li>name: Ginny Doe </li></ul></blockquote><p><b>Additional Insurance Card Information</b>: </p><blockquote><div><p>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.</p>\n</div></blockquote><p><b>Additional Insurance Card Information</b>: <a href=\"InsurancePlan-SBCExampleHMO.html\">Summary of Benefits and Coverage - Acme Gold Plus HMO</a></p><p><b>Card Issue Date</b>: 2020-12-15</p><blockquote><p><b>Color Palette</b></p><ul><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #00bfff}\">#00bfff</span></li><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #000000}\">#000000</span></li><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #ceebf5}\">#ceebf5</span></li></ul></blockquote><blockquote><p><b>Logo</b></p><ul><li>description: Company logo</li><li>image: image/png:  </li><li>label: ACME Inc.</li></ul></blockquote><blockquote><p><b>QR Code</b></p><ul><li>description: Usage text for this QR code for the end user</li><li>image: image/png:  </li><li>label: Some label for this QR code</li></ul></blockquote><blockquote><p><b>Barcode</b></p><ul><li>description: Usage text for this Barcode for the end user</li><li>image: image/png:  </li><li>label: Some label for this Barcode</li></ul></blockquote><blockquote><p><b>Supporting image</b></p><ul><li>description: Image of the front of the member's physical insurance card showing plan name, member ID, and group number</li><li>image: image/jpeg:  </li><li>label: Front of insurance card</li></ul></blockquote><blockquote><p><b>Supporting image</b></p><ul><li>description: Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information</li><li>image: image/jpeg:  </li><li>label: Back of insurance card</li></ul></blockquote><p><b>identifier</b>: Member Number/102345672-02</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><p><b>subscriber</b>: <a href=\"Patient-Example-Patient1.html\">John Doe</a></p><p><b>subscriberId</b>: 102345672-01</p><p><b>beneficiary</b>: <a href=\"Patient-Example-Patient2.html\">Jane Doe</a></p><p><b>dependent</b>: 02</p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship spouse}\">Spouse</span></p><p><b>period</b>: 2021-01-01 --&gt; (ongoing)</p><p><b>payor</b>: <a href=\"Organization-Example-PayerOrganization1.html\">Acme Insurance Co</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}\">Group</span></p><p><b>value</b>: 993355</p><p><b>name</b>: Stars Inc</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></p><p><b>value</b>: 11461128</p><p><b>name</b>: Acme Gold Plus</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS division}\">Division</span></p><p><b>value</b>: 11</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS network}\">Network</span></p><p><b>value</b>: 561490</p><p><b>name</b>: Acme Gold Plus South</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxbin}\">RX BIN</span></p><p><b>value</b>: 100045</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}\">RX PCN</span></p><p><b>value</b>: 1234000</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamOutDed}\">Family Out of Network Deductible</span></p><p><b>value</b>: <span title=\"US Dollar\">$10,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamInDed}\">Family In Network Deductible</span></p><p><b>value</b>: <span title=\"US Dollar\">$8,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxOutDed}\">Family Pharmacy Out of Network Deductible</span></p><p><b>value</b>: <span title=\"US Dollar\">$2,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxInDed}\">Family Pharmacy In Network Deductible</span></p><p><b>value</b>: <span title=\"US Dollar\">$1,500.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamOutMax}\">Family Out of Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title=\"US Dollar\">$12,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamInMax}\">Family In Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title=\"US Dollar\">$10,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxOutMax}\">Family Pharmacy Out of Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title=\"US Dollar\">$3,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxInMax}\">Family Pharmacy In Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title=\"US Dollar\">$2,000.00</span> (USD)</p></blockquote></div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "memberId"^^xsd:anyURI ;
    fhir:l fhir:memberId       ] ;
    fhir:value [
    a fhir:String ;
    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:String ;
    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:String ;
    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:String ;
    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-AdditionalCardInformation-extension"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension>     ] ;
    fhir:value [
    a fhir:Reference ;
    fhir:l fhir:InsurancePlan/SBCExampleHMO ;
    fhir:reference [ fhir:v "InsurancePlan/SBCExampleHMO" ] ;
    fhir:display [ fhir:v "Summary of Benefits and Coverage - Acme Gold Plus HMO" ]     ]
      ] [
    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 "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 "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "ACME Inc."       ]     ] ) ;
    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 "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 "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some label for this QR code"       ]     ] ) ;
    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 "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 "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Some label for this Barcode"       ]     ] ) ;
    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 "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Image of the front of the member's physical insurance card showing plan name, member ID, and group number"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/jpeg" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Front of insurance card"       ]     ] ) ;
    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:extension [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information"       ]     ] [
    fhir:url [
    fhir:v "image"^^xsd:anyURI ;
    fhir:l fhir:image       ] ;
    fhir:value [
    a fhir:Attachment ;
    fhir:contentType [ fhir:v "image/jpeg" ] ;
    fhir:data [ fhir:v " "^^xsd:base64Binary ]       ]     ] [
    fhir:url [
    fhir:v "label"^^xsd:anyURI ;
    fhir:l fhir:label       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Back of insurance card"       ]     ] ) ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    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"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] ) . #