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 Coverage: Example-Coverage-FSH

Page standards status: Informative

version: 1; Last updated: 2021-04-06 10:49:02+0000

Profile: C4DIC Coverage

> Plan Beneficiaries

> - memberId: 102345672-01
> - name: John Doe

> Plan Beneficiaries

> - memberId: 102345672-02
> - name: jane Doe

> Plan Beneficiaries

> - memberId: 102345672-03
> - name: Jimmy Doe

> Plan Beneficiaries

> - memberId: 102345672-04
> - name: Ginny Doe

Additional Insurance Card Information:

> If you use a TTY, call 711. You may be asked to present this card when you receive care or fill a perscription. This card does not gaurentee coverage. Intentionally misusing this card may be considered fraud or a violation of the law. We encourage you to use a primary care physician as a valuable resource and personal health advocate.

Additional Insurance Card Information: Summary of Benefits and Coverage - Acme Gold Plus HMO

Card Issue Date: 2020-12-15

> Color Palette

> - http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension: #00bfff
> - http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension: #000000
> - http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension: #ceebf5

> Logo

> - description: Company logo
> - image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
> - label: ACME Inc.

> QR Code

> - description: Usage text for this QR code for the end user
> - image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
> - label: Some label for this QR code

> Barcode

> - description: Usage text for this Barcode for the end user
> - image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
> - label: Some label for this Barcode

> Supporting image

> - description: Image of the front of the member's physical insurance card showing plan name, member ID, and group number
> - image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...
> - label: Front of insurance card

> Supporting image

> - description: Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information
> - image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...
> - label: Back of insurance card

identifier: Member Number/102345672-02

status: Active

type: health insurance plan policy

subscriber: John Doe

subscriberId: 102345672-01

beneficiary: Jane Doe

dependent: 02

relationship: Spouse

period: 2021-01-01 --> (ongoing)

payor: Acme Insurance Co

> class

> type: Group

> value: 993355

> name: Stars Inc

> class

> type: Plan

> value: 11461128

> name: Acme Gold Plus

> class

> type: Division

> value: 11

> class

> type: Network

> value: 561490

> name: Acme Gold Plus South

> class

> type: RX BIN

> value: 100045

> class

> type: RX PCN

> value: 1234000

> costToBeneficiary

> type: Family Out of Network Deductible

> value: $10,000.00 (USD)

> costToBeneficiary

> type: Family In Network Deductible

> value: $8,000.00 (USD)

> costToBeneficiary

> type: Family Pharmacy Out of Network Deductible

> value: $2,000.00 (USD)

> costToBeneficiary

> type: Family Pharmacy In Network Deductible

> value: $1,500.00 (USD)

> costToBeneficiary

> type: Family Out of Network Out of Pocket Maximum

> value: $12,000.00 (USD)

> costToBeneficiary

> type: Family In Network Out of Pocket Maximum

> value: $10,000.00 (USD)

> costToBeneficiary

> type: Family Pharmacy Out of Network Out of Pocket Maximum

> value: $3,000.00 (USD)

> costToBeneficiary

> type: Family Pharmacy In Network Out of Pocket Maximum

> value: $2,000.00 (USD)