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

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