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

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

Page standards status: Informative

Raw xml | Download

    <InsurancePlan xmlns="http://hl7.org/fhir">
      <id value="SBCExampleHMO"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan"/>
      </meta>
      <text>
        <status value="extensions"/>
        <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><blockquote><p><b>Benefit Limitation Extension</b></p><ul><li>limitText: Limited to network specialists only; out-of-network not covered except in emergencies</li></ul></blockquote><blockquote><p><b>Benefit Limitation Extension</b></p><ul><li>limitText: Limited to 35 visits per plan year</li><li>limitType: <span title="Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type visits}">Visits</span></li><li>limitValue: 35 visits</li><li>limitPeriod: <span title="Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period plan-year}">Plan Year</span></li></ul></blockquote><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><blockquote><p><b>Benefit Limitation Extension</b></p><ul><li>limitText: Copay waived if admitted to hospital</li></ul></blockquote><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><p><b>network</b>: <a href="Organization-ExampleValueChoiceNetwork.html">Sample Health Value Choice Network</a></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>Deductible Applies Extension</b>: false</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>Cost Applies To Network Extension</b>: <a href="Organization-ExampleValueChoiceNetwork.html">Organization Sample Health Value Choice Network</a></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>qualifiers</b>: <span title="Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier value-choice}">Value Choice Provider</span></p><p><b>value</b>: 0 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 in-network}">In Network</span></p><p><b>qualifiers</b>: <span title="Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier standard}">Standard Provider</span></p><p><b>value</b>: 50 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 in-network}">In Network</span></p><p><b>qualifiers</b>: <span title="Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier virtual}">Virtual Visit</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 emergency-room-care}">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>Benefit Limitation Extension</b></p><ul><li>limitText: Copay waived if admitted</li></ul></blockquote><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><blockquote><p><b>Benefit Limitation Extension</b></p><ul><li>limitText: Prior authorization required</li></ul></blockquote><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>Deductible Applies Extension</b>: true</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>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata">
        <extension url="sbcVersionDate">
          <valueDate value="2021-01-01"/>
        </extension>
        <extension url="minimumEssentialCoverage">
          <valueBoolean value="true"/>
        </extension>
        <extension url="minimumValue">
          <valueBoolean value="true"/>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services">
        <extension url="service">
          <extension url="serviceType">
            <valueCodeableConcept>
              <text value="Cosmetic surgery"/>
            </valueCodeableConcept>
          </extension>
          <extension url="description">
            <valueString value="Services for cosmetic purposes are not covered"/>
          </extension>
        </extension>
        <extension url="service">
          <extension url="serviceType">
            <valueCodeableConcept>
              <text value="Weight loss programs"/>
            </valueCodeableConcept>
          </extension>
          <extension url="description">
            <valueString
                         value="Weight loss programs except when medically necessary"/>
          </extension>
        </extension>
      </extension>
      <identifier>
        <system value="https://www.cms.gov/CCIIO/Resources/Data-Resources/hios"/>
        <value value="12345CA0010001-01"/>
      </identifier>
      <status value="active"/>
      <name value="Sample Health HMO Gold Plan"/>
      <period>
        <start value="2025-01-01"/>
        <end value="2025-12-31"/>
      </period>
      <ownedBy>🔗
        <reference value="Organization/ExampleIssuerOrg"/>
        <display value="Sample Health Insurance Company"/>
      </ownedBy>
      <administeredBy>🔗
        <reference value="Organization/ExampleIssuerOrg"/>
      </administeredBy>
      <contact>
        <purpose>
          <text value="General Questions"/>
        </purpose>
        <telecom>
          <system value="phone"/>
          <value value="1-800-123-4567"/>
        </telecom>
        <telecom>
          <system value="url"/>
          <value value="https://www.samplehealth.com"/>
        </telecom>
      </contact>
      <contact>
        <purpose>
          <text value="Uniform Glossary"/>
        </purpose>
        <telecom>
          <system value="url"/>
          <value value="https://www.healthcare.gov/sbc-glossary/"/>
        </telecom>
      </contact>
      <coverage>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
            <code value="HIP"/>
            <display value="health insurance plan policy"/>
          </coding>
        </type>
        <benefit>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="preventive-care"/>
            </coding>
          </type>
          <requirement
                       value="No prior authorization required for in-network preventive services"/>
        </benefit>
        <benefit>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="primary-care-visit"/>
            </coding>
          </type>
          <requirement value="No referral required"/>
        </benefit>
        <benefit>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
            <extension url="limitText">
              <valueString
                           value="Limited to network specialists only; out-of-network not covered except in emergencies"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
            <extension url="limitText">
              <valueString value="Limited to 35 visits per plan year"/>
            </extension>
            <extension url="limitType">
              <valueCodeableConcept>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type"/>
                  <code value="visits"/>
                  <display value="Visits"/>
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension url="limitValue">
              <valueQuantity>
                <value value="35"/>
                <unit value="visits"/>
              </valueQuantity>
            </extension>
            <extension url="limitPeriod">
              <valueCodeableConcept>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period"/>
                  <code value="plan-year"/>
                  <display value="Plan Year"/>
                </coding>
              </valueCodeableConcept>
            </extension>
          </extension>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="specialist-visit"/>
            </coding>
          </type>
          <requirement value="Referral required from primary care physician"/>
        </benefit>
        <benefit>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
            <extension url="limitText">
              <valueString value="Copay waived if admitted to hospital"/>
            </extension>
          </extension>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="emergency-room-care"/>
            </coding>
          </type>
        </benefit>
        <benefit>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="hospital-inpatient"/>
            </coding>
          </type>
          <requirement
                       value="Prior authorization required for non-emergency admissions"/>
        </benefit>
      </coverage>
      <plan>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type"/>
            <code value="HMO"/>
          </coding>
        </type>
        <network>🔗
          <reference value="Organization/ExampleValueChoiceNetwork"/>
          <display value="Sample Health Value Choice Network"/>
        </network>
        <generalCost>
          <type>
            <text value="Individual Deductible"/>
          </type>
          <cost>
            <value value="1500"/>
            <currency value="USD"/>
          </cost>
          <comment value="Individual in-network deductible"/>
        </generalCost>
        <generalCost>
          <type>
            <text value="Family Deductible"/>
          </type>
          <cost>
            <value value="3000"/>
            <currency value="USD"/>
          </cost>
        </generalCost>
        <generalCost>
          <type>
            <text value="Individual Out-of-Pocket Maximum"/>
          </type>
          <cost>
            <value value="6000"/>
            <currency value="USD"/>
          </cost>
        </generalCost>
        <generalCost>
          <type>
            <text value="Family Out-of-Pocket Maximum"/>
          </type>
          <cost>
            <value value="12000"/>
            <currency value="USD"/>
          </cost>
        </generalCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="preventive-care"/>
            </coding>
          </category>
          <benefit>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="preventive-care"/>
              </coding>
            </type>
            <cost>
              <type>
                <text value="No charge"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Not covered"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="primary-care-visit"/>
            </coding>
          </category>
          <benefit>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="primary-care-visit"/>
              </coding>
            </type>
            <cost>
              <extension
                         url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
                <valueBoolean value="false"/>
              </extension>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <value>
                <value value="25"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Not covered"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="specialist-visit"/>
            </coding>
          </category>
          <benefit>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="specialist-visit"/>
              </coding>
            </type>
            <cost>
              <extension
                         url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network">
                <valueReference>🔗
                  <reference value="Organization/ExampleValueChoiceNetwork"/>
                </valueReference>
              </extension>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <qualifiers>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier"/>
                  <code value="value-choice"/>
                  <display value="Value Choice Provider"/>
                </coding>
              </qualifiers>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <qualifiers>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier"/>
                  <code value="standard"/>
                  <display value="Standard Provider"/>
                </coding>
              </qualifiers>
              <value>
                <value value="50"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <qualifiers>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier"/>
                  <code value="virtual"/>
                  <display value="Virtual Visit"/>
                </coding>
              </qualifiers>
              <value>
                <value value="10"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Not covered"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="emergency-room-care"/>
            </coding>
          </category>
          <benefit>
            <extension
                       url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
              <extension url="limitText">
                <valueString value="Copay waived if admitted"/>
              </extension>
            </extension>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="emergency-room-care"/>
              </coding>
            </type>
            <cost>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <value>
                <value value="350"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="350"/>
                <unit value="USD"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="generic-drugs"/>
            </coding>
          </category>
          <benefit>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="generic-drugs"/>
              </coding>
            </type>
            <cost>
              <type>
                <text value="Copayment"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <value>
                <value value="10"/>
                <unit value="USD"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Not covered"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="USD"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
        <specificCost>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
              <code value="hospital-inpatient"/>
            </coding>
          </category>
          <benefit>
            <extension
                       url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
              <extension url="limitText">
                <valueString value="Prior authorization required"/>
              </extension>
            </extension>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
                <code value="hospital-inpatient"/>
              </coding>
            </type>
            <cost>
              <extension
                         url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
                <valueBoolean value="true"/>
              </extension>
              <type>
                <text value="Coinsurance"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="in-network"/>
                  <display value="In Network"/>
                </coding>
              </applicability>
              <value>
                <value value="20"/>
                <unit value="%"/>
              </value>
            </cost>
            <cost>
              <type>
                <text value="Not covered"/>
              </type>
              <applicability>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/applicability"/>
                  <code value="out-of-network"/>
                  <display value="Out of Network"/>
                </coding>
              </applicability>
              <value>
                <value value="0"/>
                <unit value="%"/>
              </value>
            </cost>
          </benefit>
        </specificCost>
      </plan>
    </InsurancePlan>