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 - TTL Representation

Page standards status: Informative

Raw ttl | Download

    @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/InsurancePlan/SBCExampleHMO> a fhir:InsurancePlan ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:Resource.id [ fhir:value "SBCExampleHMO"] ;
      fhir:Resource.meta [
         fhir:Meta.profile [
           fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan" ;
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan>
         ]
      ] ;
      fhir:DomainResource.text [
         fhir:Narrative.status [ fhir:value "extensions" ] ;
         fhir:Narrative.div "<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>"
      ] ;
      fhir:DomainResource.extension [
         fhir:index 0 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "sbcVersionDate" ] ;
           fhir:Extension.valueDate [ fhir:value "2021-01-01"^^xsd:date ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "minimumEssentialCoverage" ] ;
           fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
         ], [
           fhir:index 2 ;
           fhir:Extension.url [ fhir:value "minimumValue" ] ;
           fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata" ]
      ], [
         fhir:index 1 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "serviceType" ] ;
             fhir:Extension.valueCodeableConcept [
               fhir:CodeableConcept.text [ fhir:value "Cosmetic surgery" ]
             ]
           ], [
             fhir:index 1 ;
             fhir:Extension.url [ fhir:value "description" ] ;
             fhir:Extension.valueString [ fhir:value "Services for cosmetic purposes are not covered" ]
           ] ;
           fhir:Extension.url [ fhir:value "service" ]
         ], [
           fhir:index 1 ;
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Extension.url [ fhir:value "serviceType" ] ;
             fhir:Extension.valueCodeableConcept [
               fhir:CodeableConcept.text [ fhir:value "Weight loss programs" ]
             ]
           ], [
             fhir:index 1 ;
             fhir:Extension.url [ fhir:value "description" ] ;
             fhir:Extension.valueString [ fhir:value "Weight loss programs except when medically necessary" ]
           ] ;
           fhir:Extension.url [ fhir:value "service" ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services" ]
      ] ;
      fhir:InsurancePlan.identifier [
         fhir:index 0 ;
         fhir:Identifier.system [ fhir:value "https://www.cms.gov/CCIIO/Resources/Data-Resources/hios" ] ;
         fhir:Identifier.value [ fhir:value "12345CA0010001-01" ]
      ] ;
      fhir:InsurancePlan.status [ fhir:value "active"] ;
      fhir:InsurancePlan.name [ fhir:value "Sample Health HMO Gold Plan"] ;
      fhir:InsurancePlan.period [
         fhir:Period.start [ fhir:value "2025-01-01"^^xsd:date ] ;
         fhir:Period.end [ fhir:value "2025-12-31"^^xsd:date ]
      ] ;
      fhir:InsurancePlan.ownedBy [
         fhir:link <http://hl7.org/fhir/Organization/ExampleIssuerOrg> ;
         fhir:Reference.reference [ fhir:value "Organization/ExampleIssuerOrg" ] ;
         fhir:Reference.display [ fhir:value "Sample Health Insurance Company" ]
      ] ;
      fhir:InsurancePlan.administeredBy [
         fhir:link <http://hl7.org/fhir/Organization/ExampleIssuerOrg> ;
         fhir:Reference.reference [ fhir:value "Organization/ExampleIssuerOrg" ]
      ] ;
      fhir:InsurancePlan.contact [
         fhir:index 0 ;
         fhir:InsurancePlan.contact.purpose [
           fhir:CodeableConcept.text [ fhir:value "General Questions" ]
         ] ;
         fhir:InsurancePlan.contact.telecom [
           fhir:index 0 ;
           fhir:ContactPoint.system [ fhir:value "phone" ] ;
           fhir:ContactPoint.value [ fhir:value "1-800-123-4567" ]
         ], [
           fhir:index 1 ;
           fhir:ContactPoint.system [ fhir:value "url" ] ;
           fhir:ContactPoint.value [ fhir:value "https://www.samplehealth.com" ]
         ]
      ], [
         fhir:index 1 ;
         fhir:InsurancePlan.contact.purpose [
           fhir:CodeableConcept.text [ fhir:value "Uniform Glossary" ]
         ] ;
         fhir:InsurancePlan.contact.telecom [
           fhir:index 0 ;
           fhir:ContactPoint.system [ fhir:value "url" ] ;
           fhir:ContactPoint.value [ fhir:value "https://www.healthcare.gov/sbc-glossary/" ]
         ]
      ] ;
      fhir:InsurancePlan.coverage [
         fhir:index 0 ;
         fhir:InsurancePlan.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:InsurancePlan.coverage.benefit [
           fhir:index 0 ;
           fhir:InsurancePlan.coverage.benefit.type [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "preventive-care" ]
             ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.requirement [ fhir:value "No prior authorization required for in-network preventive services" ]
         ], [
           fhir:index 1 ;
           fhir:InsurancePlan.coverage.benefit.type [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "primary-care-visit" ]
             ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.requirement [ fhir:value "No referral required" ]
         ], [
           fhir:index 2 ;
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Element.extension [
               fhir:index 0 ;
               fhir:Extension.url [ fhir:value "limitText" ] ;
               fhir:Extension.valueString [ fhir:value "Limited to network specialists only; out-of-network not covered except in emergencies" ]
             ] ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ]
           ], [
             fhir:index 1 ;
             fhir:Element.extension [
               fhir:index 0 ;
               fhir:Extension.url [ fhir:value "limitText" ] ;
               fhir:Extension.valueString [ fhir:value "Limited to 35 visits per plan year" ]
             ], [
               fhir:index 1 ;
               fhir:Extension.url [ fhir:value "limitType" ] ;
               fhir:Extension.valueCodeableConcept [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type" ] ;
                   fhir:Coding.code [ fhir:value "visits" ] ;
                   fhir:Coding.display [ fhir:value "Visits" ]
                 ]
               ]
             ], [
               fhir:index 2 ;
               fhir:Extension.url [ fhir:value "limitValue" ] ;
               fhir:Extension.valueQuantity [
                 fhir:Quantity.value [ fhir:value "35"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "visits" ]
               ]
             ], [
               fhir:index 3 ;
               fhir:Extension.url [ fhir:value "limitPeriod" ] ;
               fhir:Extension.valueCodeableConcept [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period" ] ;
                   fhir:Coding.code [ fhir:value "plan-year" ] ;
                   fhir:Coding.display [ fhir:value "Plan Year" ]
                 ]
               ]
             ] ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.type [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "specialist-visit" ]
             ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.requirement [ fhir:value "Referral required from primary care physician" ]
         ], [
           fhir:index 3 ;
           fhir:Element.extension [
             fhir:index 0 ;
             fhir:Element.extension [
               fhir:index 0 ;
               fhir:Extension.url [ fhir:value "limitText" ] ;
               fhir:Extension.valueString [ fhir:value "Copay waived if admitted to hospital" ]
             ] ;
             fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.type [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "emergency-room-care" ]
             ]
           ]
         ], [
           fhir:index 4 ;
           fhir:InsurancePlan.coverage.benefit.type [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "hospital-inpatient" ]
             ]
           ] ;
           fhir:InsurancePlan.coverage.benefit.requirement [ fhir:value "Prior authorization required for non-emergency admissions" ]
         ]
      ] ;
      fhir:InsurancePlan.plan [
         fhir:index 0 ;
         fhir:InsurancePlan.plan.type [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type" ] ;
             fhir:Coding.code [ fhir:value "HMO" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.network [
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/Organization/ExampleValueChoiceNetwork> ;
           fhir:Reference.reference [ fhir:value "Organization/ExampleValueChoiceNetwork" ] ;
           fhir:Reference.display [ fhir:value "Sample Health Value Choice Network" ]
         ] ;
         fhir:InsurancePlan.plan.generalCost [
           fhir:index 0 ;
           fhir:InsurancePlan.plan.generalCost.type [
             fhir:CodeableConcept.text [ fhir:value "Individual Deductible" ]
           ] ;
           fhir:InsurancePlan.plan.generalCost.cost [
             fhir:Money.value [ fhir:value "1500"^^xsd:decimal ] ;
             fhir:Money.currency [ fhir:value "USD" ]
           ] ;
           fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "Individual in-network deductible" ]
         ], [
           fhir:index 1 ;
           fhir:InsurancePlan.plan.generalCost.type [
             fhir:CodeableConcept.text [ fhir:value "Family Deductible" ]
           ] ;
           fhir:InsurancePlan.plan.generalCost.cost [
             fhir:Money.value [ fhir:value "3000"^^xsd:decimal ] ;
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 2 ;
           fhir:InsurancePlan.plan.generalCost.type [
             fhir:CodeableConcept.text [ fhir:value "Individual Out-of-Pocket Maximum" ]
           ] ;
           fhir:InsurancePlan.plan.generalCost.cost [
             fhir:Money.value [ fhir:value "6000"^^xsd:decimal ] ;
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 3 ;
           fhir:InsurancePlan.plan.generalCost.type [
             fhir:CodeableConcept.text [ fhir:value "Family Out-of-Pocket Maximum" ]
           ] ;
           fhir:InsurancePlan.plan.generalCost.cost [
             fhir:Money.value [ fhir:value "12000"^^xsd:decimal ] ;
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.specificCost [
           fhir:index 0 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "preventive-care" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "preventive-care" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "No charge" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Not covered" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ]
           ]
         ], [
           fhir:index 1 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "primary-care-visit" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "primary-care-visit" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:Element.extension [
                 fhir:index 0 ;
                 fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ;
                 fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "25"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Not covered" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ]
           ]
         ], [
           fhir:index 2 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "specialist-visit" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "specialist-visit" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:Element.extension [
                 fhir:index 0 ;
                 fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network" ] ;
                 fhir:Extension.valueReference [
                   fhir:link <http://hl7.org/fhir/Organization/ExampleValueChoiceNetwork> ;
                   fhir:Reference.reference [ fhir:value "Organization/ExampleValueChoiceNetwork" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
                 fhir:index 0 ;
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier" ] ;
                   fhir:Coding.code [ fhir:value "value-choice" ] ;
                   fhir:Coding.display [ fhir:value "Value Choice Provider" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
                 fhir:index 0 ;
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier" ] ;
                   fhir:Coding.code [ fhir:value "standard" ] ;
                   fhir:Coding.display [ fhir:value "Standard Provider" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 2 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [
                 fhir:index 0 ;
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier" ] ;
                   fhir:Coding.code [ fhir:value "virtual" ] ;
                   fhir:Coding.display [ fhir:value "Virtual Visit" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 3 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Not covered" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ]
           ]
         ], [
           fhir:index 3 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "emergency-room-care" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:Element.extension [
               fhir:index 0 ;
               fhir:Element.extension [
                 fhir:index 0 ;
                 fhir:Extension.url [ fhir:value "limitText" ] ;
                 fhir:Extension.valueString [ fhir:value "Copay waived if admitted" ]
               ] ;
               fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "emergency-room-care" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "350"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "350"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ]
           ]
         ], [
           fhir:index 4 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "generic-drugs" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "generic-drugs" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Copayment" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "10"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Not covered" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "USD" ]
               ]
             ]
           ]
         ], [
           fhir:index 5 ;
           fhir:InsurancePlan.plan.specificCost.category [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
               fhir:Coding.code [ fhir:value "hospital-inpatient" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit [
             fhir:index 0 ;
             fhir:Element.extension [
               fhir:index 0 ;
               fhir:Element.extension [
                 fhir:index 0 ;
                 fhir:Extension.url [ fhir:value "limitText" ] ;
                 fhir:Extension.valueString [ fhir:value "Prior authorization required" ]
               ] ;
               fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.type [
               fhir:CodeableConcept.coding [
                 fhir:index 0 ;
                 fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ;
                 fhir:Coding.code [ fhir:value "hospital-inpatient" ]
               ]
             ] ;
             fhir:InsurancePlan.plan.specificCost.benefit.cost [
               fhir:index 0 ;
               fhir:Element.extension [
                 fhir:index 0 ;
                 fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ;
                 fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Coinsurance" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "in-network" ] ;
                   fhir:Coding.display [ fhir:value "In Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "%" ]
               ]
             ], [
               fhir:index 1 ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.type [
                 fhir:CodeableConcept.text [ fhir:value "Not covered" ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [
                 fhir:CodeableConcept.coding [
                   fhir:index 0 ;
                   fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ;
                   fhir:Coding.code [ fhir:value "out-of-network" ] ;
                   fhir:Coding.display [ fhir:value "Out of Network" ]
                 ]
               ] ;
               fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
                 fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "%" ]
               ]
             ]
           ]
         ]
      ] .

    <http://hl7.org/fhir/Organization/ExampleIssuerOrg> a fhir:Organization .

    <http://hl7.org/fhir/Organization/ExampleValueChoiceNetwork> a fhir:Organization .

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

    <http://hl7.org/fhir/InsurancePlan/SBCExampleHMO.ttl> a owl:Ontology ;
      owl:imports fhir:fhir.ttl ;
      owl:versionIRI <http://build.fhir.org/InsurancePlan/SBCExampleHMO.ttl> .