Generated Narrative: Coverage

Plan Beneficiaries

url

memberId

value: 102345672-01

url

name

value: John Doe

Plan Beneficiaries

url

memberId

value: 102345672-02

url

name

value: jane Doe

Plan Beneficiaries

url

memberId

value: 102345672-03

url

name

value: Jimmy Doe

Plan Beneficiaries

url

memberId

value: 102345672-04

url

name

value: 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.

Card Issue Date: 2020-12-15

Color Palette

url

Background Color

value: #00bfff (IEC 61966-2-1: Colour measurement and management - Part 2-1: Colour management - Default RGB colour space - sRGB##00bfff)

url

Foreground Color

value: #000000 (IEC 61966-2-1: Colour measurement and management - Part 2-1: Colour management - Default RGB colour space - sRGB##000000)

url

Highlight Color

value: #ceebf5 (IEC 61966-2-1: Colour measurement and management - Part 2-1: Colour management - Default RGB colour space - sRGB##ceebf5)

Logo

url

description

value: Company logo

url

image

value:

url

label

value: ACME Inc.

QR Code

url

description

value: Usage text for this QR code for the end user

url

image

value:

url

label

value: Some label for this QR code

Barcode

url

description

value: Usage text for this Barcode for the end user

url

image

value:

url

label

value: Some label for this Barcode

Supporting image

url

description

value: Some text for the end user about the usage/meaning of this image

url

image

value:

url

label

value: Some label text

identifier: Member Number/102345672-02

status: active

type: health insurance plan policy (ActCode#HIP)

subscriber: Patient/Example-Patient1: John Doe " DOE"

subscriberId: 102345672-01

beneficiary: Patient/Example-Patient2: Jane Doe " DOE"

dependent: 02

relationship: Spouse (SubscriberPolicyholder Relationship Codes#spouse)

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

payor: Organization/Example-PayerOrganization1: Acme Insurance Co "Acme Insurance Co"

class

type: Group (Coverage Class Codes#group)

value: 993355

name: Stars Inc

class

type: Plan (Coverage Class Codes#plan)

value: 11461128

name: Acme Gold Plus

class

type: Division (C4DIC Extended Coverage Class#division)

value: 11

class

type: Network (C4DIC Extended Coverage Class#network)

value: 561490

name: Acme Gold Plus South

class

type: RX BIN (Coverage Class Codes#rxbin)

value: 100045

class

type: RX PCN (Coverage Class Codes#rxpcn)

value: 1234000

costToBeneficiary

type: Family Out of Network Deductible (C4DIC Extended Copay Type#FamOutDed)

value: $10,000.00 (USD)

costToBeneficiary

type: Family In Network Deductible (C4DIC Extended Copay Type#FamInDed)

value: $8,000.00 (USD)

costToBeneficiary

type: Family Pharmacy Out of Network Deductible (C4DIC Extended Copay Type#FamRxOutDed)

value: $2,000.00 (USD)

costToBeneficiary

type: Family Pharmacy In Network Deductible (C4DIC Extended Copay Type#FamRxInDed)

value: $1,500.00 (USD)

costToBeneficiary

type: Family Out of Network Out of Pocket Maximum (C4DIC Extended Copay Type#FamOutMax)

value: $12,000.00 (USD)

costToBeneficiary

type: Family In Network Out of Pocket Maximum (C4DIC Extended Copay Type#FamInMax)

value: $10,000.00 (USD)

costToBeneficiary

type: Family Pharmacy Out of Network Out of Pocket Maximum (C4DIC Extended Copay Type#FamRxOutMax)

value: $3,000.00 (USD)

costToBeneficiary

type: Family Pharmacy In Network Out of Pocket Maximum (C4DIC Extended Copay Type#FamRxInMax)

value: $2,000.00 (USD)