CARIN Digital Insurance Card
2.0.0-ballot - STU 2 Ballot

CARIN Digital Insurance Card - Downloaded Version 2.0.0-ballot 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 rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

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

    <http://hl7.org/fhir/Coverage/Example-Coverage1> a fhir:Coverage ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:Resource.id [ fhir:value "Example-Coverage1"] ;
      fhir:Resource.meta [
         fhir:Meta.versionId [ fhir:value "1" ] ;
         fhir:Meta.lastUpdated [ fhir:value "2021-04-06T10:49:02.473+00:00"^^xsd:dateTime ] ;
         fhir:Meta.profile [
           fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage" ;
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage>
         ]
      ] ;
      fhir:DomainResource.text [
         fhir:Narrative.status [ fhir:value "generated" ] ;
         fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Acme Gold Plus</div>"
      ] ;
      fhir:DomainResource.extension [
         fhir:index 0 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "memberId" ] ;
           fhir:Extension.valueId [ fhir:value "102345672-01" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "name" ] ;
           fhir:Extension.valueHumanName [
             fhir:HumanName.family [ fhir:value "Doe" ] ;
             fhir:HumanName.given [
               fhir:value "John" ;
               fhir:index 0
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension" ]
      ], [
         fhir:index 1 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "memberId" ] ;
           fhir:Extension.valueId [ fhir:value "102345672-02" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "name" ] ;
           fhir:Extension.valueHumanName [
             fhir:HumanName.family [ fhir:value "Doe" ] ;
             fhir:HumanName.given [
               fhir:value "Jane" ;
               fhir:index 0
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension" ]
      ], [
         fhir:index 2 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "memberId" ] ;
           fhir:Extension.valueId [ fhir:value "102345672-03" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "name" ] ;
           fhir:Extension.valueHumanName [
             fhir:HumanName.family [ fhir:value "Doe" ] ;
             fhir:HumanName.given [
               fhir:value "Jimmy" ;
               fhir:index 0
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension" ]
      ], [
         fhir:index 3 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "memberId" ] ;
           fhir:Extension.valueId [ fhir:value "102345672-04" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "name" ] ;
           fhir:Extension.valueHumanName [
             fhir:HumanName.family [ fhir:value "Doe" ] ;
             fhir:HumanName.given [
               fhir:value "Ginny" ;
               fhir:index 0
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension" ]
      ], [
         fhir:index 4 ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension" ] ;
         fhir:Extension.valueAnnotation [
           fhir:Annotation.text [ fhir:value "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:index 5 ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension" ] ;
         fhir:Extension.valueDate [ fhir:value "2020-12-15"^^xsd:date ]
      ], [
         fhir:index 6 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension" ] ;
           fhir:Extension.valueCodeableConcept [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/IECColourManagement" ] ;
               fhir:Coding.code [ fhir:value "#00bfff" ]
             ]
           ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension" ] ;
           fhir:Extension.valueCodeableConcept [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/IECColourManagement" ] ;
               fhir:Coding.code [ fhir:value "#000000" ]
             ]
           ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension" ] ;
           fhir:Extension.valueCodeableConcept [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/IECColourManagement" ] ;
               fhir:Coding.code [ fhir:value "#ceebf5" ]
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension" ]
      ], [
         fhir:index 7 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "label" ] ;
           fhir:Extension.valueString [ fhir:value "ACME Inc." ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "description" ] ;
           fhir:Extension.valueString [ fhir:value "Company logo" ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "image" ] ;
           fhir:Extension.valueAttachment [
             fhir:Attachment.contentType [ fhir:value "image/png" ] ;
             fhir:Attachment.data [ fhir:value " "^^xsd:base64Binary ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension" ]
      ], [
         fhir:index 8 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "label" ] ;
           fhir:Extension.valueString [ fhir:value "Some lable for this QR code" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "description" ] ;
           fhir:Extension.valueString [ fhir:value "Usage text for this QR code for the end user" ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "image" ] ;
           fhir:Extension.valueAttachment [
             fhir:Attachment.contentType [ fhir:value "image/png" ] ;
             fhir:Attachment.data [ fhir:value " "^^xsd:base64Binary ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension" ]
      ], [
         fhir:index 9 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "label" ] ;
           fhir:Extension.valueString [ fhir:value "Some label for this Barcode" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "description" ] ;
           fhir:Extension.valueString [ fhir:value "Usage text for this Barcode for the end user" ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "image" ] ;
           fhir:Extension.valueAttachment [
             fhir:Attachment.contentType [ fhir:value "image/png" ] ;
             fhir:Attachment.data [ fhir:value " "^^xsd:base64Binary ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension" ]
      ], [
         fhir:index 10 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "label" ] ;
           fhir:Extension.valueString [ fhir:value "Some label text" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "description" ] ;
           fhir:Extension.valueString [ fhir:value "Some text for the end user about the usage/meaning of this image" ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "image" ] ;
           fhir:Extension.valueAttachment [
             fhir:Attachment.contentType [ fhir:value "image/png" ] ;
             fhir:Attachment.data [ fhir:value " "^^xsd:base64Binary ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension" ]
      ] ;
      fhir:Coverage.identifier [
         fhir:index 0 ;
         fhir:Identifier.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ;
             fhir:Coding.code [ fhir:value "MB" ] ;
             fhir:Coding.display [ fhir:value "Member Number" ]
           ]
         ] ;
         fhir:Identifier.system [ fhir:value "https://www.acmeinsurance.com/glossary/memberid" ] ;
         fhir:Identifier.value [ fhir:value "102345672-02" ] ;
         fhir:Identifier.assigner [
           fhir:Reference.display [ fhir:value "Acme Insurance Co" ]
         ]
      ] ;
      fhir:Coverage.status [ fhir:value "active"] ;
      fhir:Coverage.type [
         fhir:CodeableConcept.coding [
           fhir:index 0 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ] ;
           fhir:Coding.code [ fhir:value "HIP" ] ;
           fhir:Coding.display [ fhir:value "health insurance plan policy" ]
         ] ;
         fhir:CodeableConcept.text [ fhir:value "health insurance plan policy" ]
      ] ;
      fhir:Coverage.subscriber [
         fhir:link <http://hl7.org/fhir/Patient/Example-Patient1> ;
         fhir:Reference.reference [ fhir:value "Patient/Example-Patient1" ] ;
         fhir:Reference.display [ fhir:value "John Doe" ]
      ] ;
      fhir:Coverage.subscriberId [ fhir:value "102345672-01"] ;
      fhir:Coverage.beneficiary [
         fhir:link <http://hl7.org/fhir/Patient/Example-Patient2> ;
         fhir:Reference.reference [ fhir:value "Patient/Example-Patient2" ] ;
         fhir:Reference.display [ fhir:value "Jane Doe" ]
      ] ;
      fhir:Coverage.dependent [ fhir:value "02"] ;
      fhir:Coverage.relationship [
         fhir:CodeableConcept.coding [
           fhir:index 0 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/subscriber-relationship" ] ;
           fhir:Coding.code [ fhir:value "spouse" ] ;
           fhir:Coding.display [ fhir:value "Spouse" ]
         ] ;
         fhir:CodeableConcept.text [ fhir:value "Spouse" ]
      ] ;
      fhir:Coverage.period [
         fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ]
      ] ;
      fhir:Coverage.payor [
         fhir:index 0 ;
         fhir:link <http://hl7.org/fhir/Organization/Example-PayerOrganization1> ;
         fhir:Reference.reference [ fhir:value "Organization/Example-PayerOrganization1" ] ;
         fhir:Reference.display [ fhir:value "Acme Insurance Co" ]
      ] ;
      fhir:Coverage.class [
         fhir:index 0 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ;
             fhir:Coding.code [ fhir:value "group" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "993355" ] ;
         fhir:Coverage.class.name [ fhir:value "Stars Inc" ]
      ], [
         fhir:index 1 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ;
             fhir:Coding.code [ fhir:value "plan" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "11461128" ] ;
         fhir:Coverage.class.name [ fhir:value "Acme Gold Plus" ]
      ], [
         fhir:index 2 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS" ] ;
             fhir:Coding.code [ fhir:value "division" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "11" ]
      ], [
         fhir:index 3 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS" ] ;
             fhir:Coding.code [ fhir:value "network" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "561490" ] ;
         fhir:Coverage.class.name [ fhir:value "Acme Gold Plus South" ]
      ], [
         fhir:index 4 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ;
             fhir:Coding.code [ fhir:value "rxbin" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "100045" ]
      ], [
         fhir:index 5 ;
         fhir:Coverage.class.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ;
             fhir:Coding.code [ fhir:value "rxpcn" ]
           ]
         ] ;
         fhir:Coverage.class.value [ fhir:value "1234000" ]
      ] ;
      fhir:Coverage.costToBeneficiary [
         fhir:index 0 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamOutDed" ] ;
             fhir:Coding.display [ fhir:value "Family Out of Network Deductible" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "10000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 1 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamInDed" ] ;
             fhir:Coding.display [ fhir:value "Family In Network Deductible" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "8000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 2 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamRxOutDed" ] ;
             fhir:Coding.display [ fhir:value "Family Pharmacy Out of Network Deductible" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "2000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 3 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamRxInDed" ] ;
             fhir:Coding.display [ fhir:value "Family Pharmacy In Network Deductible" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "1500.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 4 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamOutMax" ] ;
             fhir:Coding.display [ fhir:value "Family Out of Network Out of Pocket Maximum" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "12000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 5 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamInMax" ] ;
             fhir:Coding.display [ fhir:value "Family In Network Out of Pocket Maximum" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "10000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 6 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamRxOutMax" ] ;
             fhir:Coding.display [ fhir:value "Family Pharmacy Out of Network Out of Pocket Maximum" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "3000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 7 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "FamRxInMax" ] ;
             fhir:Coding.display [ fhir:value "Family Pharmacy In Network Out of Pocket Maximum" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Money.value [ fhir:value "2000.00"^^xsd:decimal ] ;
           fhir:Money.currency [ fhir:value "USD" ]
         ]
      ], [
         fhir:index 8 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ;
             fhir:Coding.code [ fhir:value "gpvisit" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension" ] ;
             fhir:Extension.valueString [ fhir:value "N/A" ]
           ]
         ]
      ], [
         fhir:index 9 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ;
             fhir:Coding.code [ fhir:value "spvisit" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension" ] ;
             fhir:Extension.valueString [ fhir:value "N/A" ]
           ]
         ]
      ], [
         fhir:index 10 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ;
             fhir:Coding.code [ fhir:value "emergency" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension" ] ;
             fhir:Extension.valueString [ fhir:value "N/A" ]
           ]
         ]
      ], [
         fhir:index 11 ;
         fhir:Coverage.costToBeneficiary.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS" ] ;
             fhir:Coding.code [ fhir:value "rx" ]
           ]
         ] ;
         fhir:Coverage.costToBeneficiary.valueMoney [
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension" ] ;
             fhir:Extension.valueString [ fhir:value "DED THEN $10/$40/$70/25%" ]
           ]
         ]
      ] .

    <http://hl7.org/fhir/Patient/Example-Patient1> a fhir:Patient .

    <http://hl7.org/fhir/Patient/Example-Patient2> a fhir:Patient .

    <http://hl7.org/fhir/Organization/Example-PayerOrganization1> a fhir:Organization .

    # - ontology header ------------------------------------------------------------

    <http://hl7.org/fhir/Coverage/Example-Coverage1.ttl> a owl:Ontology ;
      owl:imports fhir:fhir.ttl ;
      owl:versionIRI <http://build.fhir.org/Coverage/Example-Coverage1.ttl> .