{
  "resourceType" : "InsurancePlan",
  "id" : "19898FL0340001-01",
  "meta" : {
    "profile" : ["https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan",
    "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot"]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan 19898FL0340001-01</b></p><a name=\"19898FL0340001-01\"> </a><a name=\"hc19898FL0340001-01\"> </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\">Profiles: <a href=\"StructureDefinition-haau3-insurance-plan.html\">haau3 Insurance Plan (Plan Benefits)</a>, <code>http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot</code></p></div><blockquote><p><b>Plan Benefits Source Release</b></p><blockquote><p><b>url</b></p>release</blockquote><p><b>value</b>: aca-2026-2026-08-10</p><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip\">https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: 954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip\">https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/network-puf.zip\">https://download.cms.gov/marketplace-puf/2026/network-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: 3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip\">https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f</p><blockquote><p><b>url</b></p>file</blockquote></blockquote><blockquote><p><b>Plan Benefits Plan Facts</b></p><ul><li>metalLevel: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type gold}\">Gold</span></li><li>csrVariation: Standard Gold On Exchange Plan</li><li>market: Individual</li><li>hsaEligible: false</li><li>effectiveDate: 2026-01-01</li><li>enrollmentEnd: 2026-12-31</li><li>outOfServiceAreaCoverage: true</li><li>outOfServiceAreaDescription: Emergency Only</li><li>outOfCountryCoverage: true</li><li>outOfCountryDescription: Emergency Only</li><li>multipleInNetworkTiers: true</li><li>deductiblesIntegrated: true</li><li>maximumIntegrated: true</li><li>primaryCareVisitsBeforeCostSharing: 0</li><li>primaryCareCopaysBeforeDeductible: 0</li><li>inpatientCopayMaxDays: 0</li></ul></blockquote><p><b>identifier</b>: <a href=\"NamingSystem-hios-plan-id.html\" title=\"A Marketplace plan's 17-character plan ID in CMS's Health Insurance Oversight System (HIOS): the 14-character standard component ID, a hyphen and a two-digit cost-sharing reduction variant (19898FL0340001-01), as CMS's Plan Attributes public use file writes it (PlanId). haau3 publishes this until CMS or HL7 publishes an identifier system for it.\">HIOSPlanId</a>/19898FL0340001-01, <a href=\"NamingSystem-hios-standard-component-id.html\" title=\"A Marketplace plan's 14-character standard component ID in CMS's Health Insurance Oversight System (HIOS), shared by every cost-sharing reduction variant of the plan (19898FL0340001), as CMS's Plan Attributes public use file writes it (StandardComponentId). haau3 publishes this until CMS or HL7 publishes an identifier system for it.\">HIOSStandardComponentId</a>/19898FL0340001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insurance-product-type qhp}\">Qualified Health Plan</span></p><p><b>name</b>: AvMed Entrust Gold 125 (2026)</p><p><b>period</b>: 2026 --&gt; 2026</p><p><b>ownedBy</b>: <a href=\"#hc19898FL0340001-01/issuer\">AvMed</a></p><p><b>coverageArea</b>: <a href=\"#hc19898FL0340001-01/state-FL\">Unnamed Location</a></p><blockquote><p><b>contact</b></p><p><b>Data Absent Reason</b>: unknown</p><p><b>purpose</b>: <span title=\"Codes:\">General Questions</span></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Provider directory</span></p><p><b>telecom</b>: <a href=\"https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&amp;brandCode=AVMED\">https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&amp;brandCode=AVMED</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Summary of Benefits and Coverage</span></p><p><b>telecom</b>: <a href=\"https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf\">https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Plan brochure</span></p><p><b>telecom</b>: <a href=\"https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf\">https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Drug list</span></p><p><b>telecom</b>: <a href=\"https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf\">https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf</a></p></blockquote><p><b>network</b>: <a href=\"#hc19898FL0340001-01/network\">AvMed HIX Network</a></p><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 primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">Primary Care Visit</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 specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Specialist Visit}\">Specialist Visit</span></p><p><b>requirement</b>: Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care.</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 urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent 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 emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient 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 facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</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 physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</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 imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</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 rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</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 mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</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 emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</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 skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</span></p></blockquote></blockquote><blockquote><p><b>plan</b></p><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Laboratory Outpatient and Professional Services}\">Laboratory Outpatient and Professional Services</span></p><p><b>Plan Benefits Source Text</b>: $10.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 10 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Other Practitioner Office Visit (Nurse, Physician Assistant)}\">Other Practitioner Office Visit (Nurse, Physician Assistant)</span></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Home Health Care Services}\">Home Health Care Services</span></p><p><b>Plan Benefits Source Text</b>: $70.00 Copay after deductible</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><p><b>deductibleApplies</b>: true</p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type HMO}\">HMO</span></p><p><b>coverageArea</b>: <a href=\"#hc19898FL0340001-01/state-FL\">Unnamed Location</a></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type monthly-premium}\">Monthly premium</span></p><p><b>comment</b>: Depends on age and where you live; not in these files.</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2,000</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">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>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2000 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</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>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $4000 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">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>4000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2,000</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">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>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2000 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</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>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $4000 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">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>4000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5,850</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">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>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5850 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</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>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $11700 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">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>11700</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5,850</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">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>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5850 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</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>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $11700 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">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>11700</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name 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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Specialist Visit}\">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent Care</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 urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $125.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 125 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">Emergency Room Care</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 emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></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}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient Care</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 hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $850.00 Copay per Stay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-stay}\">Per stay</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 850 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</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 facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $650.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 650 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $650.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 650 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</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 physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: No Charge after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</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 imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: Combined limit for all outpatient therapy plus chiropractic.</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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 mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: The cost sharing applies to outpatient office visits only. All other outpatient services [e.g., Detox, Neuropsychology, Psychological Testing] may be subject to additional cost sharing.</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></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-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</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 emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $200.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 200 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $200.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 200 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></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 skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</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 skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00 Copay per Day after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</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:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</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>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #issuer</b></p><a name=\"19898FL0340001-01/issuer\"> </a><a name=\"hc19898FL0340001-01/issuer\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">AvMed (Health Insurance Oversight System: HIOSIssuerId#19898)</p><hr/></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #network</b></p><a name=\"19898FL0340001-01/network\"> </a><a name=\"hc19898FL0340001-01/network\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">AvMed HIX Network</p><hr/></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Location #state-FL</b></p><a name=\"19898FL0340001-01/state-FL\"> </a><a name=\"hc19898FL0340001-01/state-FL\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Unnamed Location</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"The physical form of the location (e.g. building, room, vehicle, road)\">Form:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/location-physical-type jdn}\">Jurisdiction</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Physical location\">Address:</td><td colspan=\"3\">FL </td></tr></table></blockquote></div>"
  },
  "contained" : [{
    "resourceType" : "Organization",
    "id" : "issuer",
    "identifier" : [{
      "type" : {
        "coding" : [{
          "system" : "https://haau3.com/fhir/CodeSystem/payor-identifier-types-cs",
          "code" : "hios-id",
          "display" : "Health Insurance Oversight System"
        }]
      },
      "system" : "https://haau3.com/fhir/NamingSystem/hios-issuer-id",
      "value" : "19898"
    }],
    "name" : "AvMed"
  },
  {
    "resourceType" : "Organization",
    "id" : "network",
    "name" : "AvMed HIX Network"
  },
  {
    "resourceType" : "Location",
    "id" : "state-FL",
    "address" : {
      "state" : "FL"
    },
    "physicalType" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/location-physical-type",
        "code" : "jdn",
        "display" : "Jurisdiction"
      }]
    }
  }],
  "extension" : [{
    "extension" : [{
      "url" : "release",
      "valueString" : "aca-2026-2026-08-10"
    },
    {
      "extension" : [{
        "url" : "downloadUrl",
        "valueUri" : "https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip"
      },
      {
        "url" : "lastModified",
        "valueDate" : "2026-08-10"
      },
      {
        "url" : "sha256",
        "valueString" : "954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2"
      }],
      "url" : "file"
    },
    {
      "extension" : [{
        "url" : "downloadUrl",
        "valueUri" : "https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip"
      },
      {
        "url" : "lastModified",
        "valueDate" : "2026-08-10"
      },
      {
        "url" : "sha256",
        "valueString" : "aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682"
      }],
      "url" : "file"
    },
    {
      "extension" : [{
        "url" : "downloadUrl",
        "valueUri" : "https://download.cms.gov/marketplace-puf/2026/network-puf.zip"
      },
      {
        "url" : "lastModified",
        "valueDate" : "2026-08-10"
      },
      {
        "url" : "sha256",
        "valueString" : "3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3"
      }],
      "url" : "file"
    },
    {
      "extension" : [{
        "url" : "downloadUrl",
        "valueUri" : "https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip"
      },
      {
        "url" : "lastModified",
        "valueDate" : "2026-08-10"
      },
      {
        "url" : "sha256",
        "valueString" : "eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f"
      }],
      "url" : "file"
    }],
    "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release"
  },
  {
    "extension" : [{
      "url" : "metalLevel",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type",
          "code" : "gold",
          "display" : "Gold-QHP"
        }],
        "text" : "Gold"
      }
    },
    {
      "url" : "csrVariation",
      "valueString" : "Standard Gold On Exchange Plan"
    },
    {
      "url" : "market",
      "valueString" : "Individual"
    },
    {
      "url" : "hsaEligible",
      "valueBoolean" : false
    },
    {
      "url" : "effectiveDate",
      "valueDate" : "2026-01-01"
    },
    {
      "url" : "enrollmentEnd",
      "valueDate" : "2026-12-31"
    },
    {
      "url" : "outOfServiceAreaCoverage",
      "valueBoolean" : true
    },
    {
      "url" : "outOfServiceAreaDescription",
      "valueString" : "Emergency Only"
    },
    {
      "url" : "outOfCountryCoverage",
      "valueBoolean" : true
    },
    {
      "url" : "outOfCountryDescription",
      "valueString" : "Emergency Only"
    },
    {
      "url" : "multipleInNetworkTiers",
      "valueBoolean" : true
    },
    {
      "url" : "deductiblesIntegrated",
      "valueBoolean" : true
    },
    {
      "url" : "maximumIntegrated",
      "valueBoolean" : true
    },
    {
      "url" : "primaryCareVisitsBeforeCostSharing",
      "valueUnsignedInt" : 0
    },
    {
      "url" : "primaryCareCopaysBeforeDeductible",
      "valueUnsignedInt" : 0
    },
    {
      "url" : "inpatientCopayMaxDays",
      "valueUnsignedInt" : 0
    }],
    "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts"
  }],
  "identifier" : [{
    "system" : "https://haau3.com/fhir/NamingSystem/hios-plan-id",
    "value" : "19898FL0340001-01"
  },
  {
    "system" : "https://haau3.com/fhir/NamingSystem/hios-standard-component-id",
    "value" : "19898FL0340001"
  }],
  "status" : "active",
  "type" : [{
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/insurance-product-type",
      "code" : "qhp",
      "display" : "Qualified Health Plan"
    }]
  }],
  "name" : "AvMed Entrust Gold 125 (2026)",
  "period" : {
    "start" : "2026",
    "end" : "2026"
  },
  "ownedBy" : {
    "reference" : "#issuer",
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      "text" : "Provider directory"
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      },
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        },
        {
          "url" : "amount",
          "valueQuantity" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
          }
        }],
        "url" : "cost"
      }],
      "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit"
    }],
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type",
        "code" : "HMO",
        "display" : "Health Maintenance Organization (HMO)"
      }],
      "text" : "HMO"
    },
    "coverageArea" : [{
      "reference" : "#state-FL"
    }],
    "generalCost" : [{
      "type" : {
        "coding" : [{
          "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type",
          "code" : "monthly-premium",
          "display" : "Monthly premium"
        }],
        "text" : "Monthly premium"
      },
      "comment" : "Depends on age and where you live; not in these files."
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$2,000"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Individual Deductible"
      },
      "cost" : {
        "value" : 2000,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "family-per-person",
            "display" : "Family, per person"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$2000 per person"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible (per person)"
      },
      "cost" : {
        "value" : 2000,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "family",
            "display" : "Family"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$4000 per group"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible"
      },
      "cost" : {
        "value" : 4000,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "tier-2",
            "display" : "In network, tier 2"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$2,000"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Individual Deductible"
      },
      "cost" : {
        "value" : 2000,
        "currency" : "USD"
      },
      "comment" : "In network tier 2, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "tier-2",
            "display" : "In network, tier 2"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "family-per-person",
            "display" : "Family, per person"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$2000 per person"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible (per person)"
      },
      "cost" : {
        "value" : 2000,
        "currency" : "USD"
      },
      "comment" : "In network tier 2, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "tier-2",
            "display" : "In network, tier 2"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "family",
            "display" : "Family"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$4000 per group"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible"
      },
      "cost" : {
        "value" : 4000,
        "currency" : "USD"
      },
      "comment" : "In network tier 2, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "out",
            "display" : "Out of Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "Not Applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Individual Deductible"
      },
      "comment" : "Out of network, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "out",
            "display" : "Out of Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "family-per-person",
            "display" : "Family, per person"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "per person not applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible (per person)"
      },
      "comment" : "Out of network, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "out",
            "display" : "Out of Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "family",
            "display" : "Family"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "per group not applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible"
      },
      "comment" : "Out of network, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "combined",
            "display" : "In and out of network combined"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "Not Applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Individual Deductible"
      },
      "comment" : "In and out of network combined, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "combined",
            "display" : "In and out of network combined"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "family-per-person",
            "display" : "Family, per person"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "per person not applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible (per person)"
      },
      "comment" : "In and out of network combined, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "combined",
            "display" : "In and out of network combined"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "family",
            "display" : "Family"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "per group not applicable"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "deductible",
          "display" : "Deductible"
        }],
        "text" : "Family Deductible"
      },
      "comment" : "In and out of network combined, for medical care and drugs: not stated"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$5,850"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "maxoutofpocket",
          "display" : "Maximum out of pocket"
        }],
        "text" : "Individual Out-of-Pocket Maximum"
      },
      "cost" : {
        "value" : 5850,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "family-per-person",
            "display" : "Family, per person"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$5850 per person"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "maxoutofpocket",
          "display" : "Maximum out of pocket"
        }],
        "text" : "Family Out-of-Pocket Maximum (per person)"
      },
      "cost" : {
        "value" : 5850,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
            "code" : "in",
            "display" : "In Network"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "family",
            "display" : "Family"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
        "valueString" : "$11700 per group"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
          "code" : "maxoutofpocket",
          "display" : "Maximum out of pocket"
        }],
        "text" : "Family Out-of-Pocket Maximum"
      },
      "cost" : {
        "value" : 11700,
        "currency" : "USD"
      },
      "comment" : "In network tier 1, for medical care and drugs"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "network",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "tier-2",
            "display" : "In network, tier 2"
          }
        },
        {
          "url" : "member",
          "valueCoding" : {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual",
            "display" : "Individual"
          }
        },
        {
          "url" : "appliesTo",
          "valueCoding" : {
            "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope",
            "code" : "medical-and-drug",
            "display" : "Medical and drugs"
          }
        }],
        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope"
      },
      {
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      "cost" : {
        "value" : 5850,
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      "comment" : "In network tier 2, for medical care and drugs"
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        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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        "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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          {
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            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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        },
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              "display" : "Copayment per service"
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            "value" : 125,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
            "code" : "USD"
          }
        },
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$250.00"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "counts-toward-maximum",
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          }],
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            "unit" : "USD",
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        },
        {
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$250.00"
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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            "text" : "Copayment"
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          "applicability" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        }]
      }]
    },
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        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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          "display" : "Emergency Room Services"
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      },
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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            "unit" : "USD",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
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              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$500.00 Copay after deductible"
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          {
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
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          "type" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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        }]
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    },
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        {
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            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
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          {
            "coding" : [{
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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            "coding" : [{
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
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              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment Percent per service"
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          "applicability" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
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            "system" : "http://unitsofmeasure.org",
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        }]
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    {
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          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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      "benefit" : [{
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            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$650.00 Copay after deductible"
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            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
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              "display" : "Copayment per service"
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
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            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        {
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
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          "type" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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            "text" : "Copayment"
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          "applicability" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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          "qualifiers" : [{
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 2"
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          },
          {
            "coding" : [{
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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            "system" : "urn:iso:std:iso:4217",
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        },
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          "extension" : [{
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            "valueString" : "100.00%"
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          "type" : {
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              "display" : "Copayment Percent per service"
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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          "value" : {
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            "system" : "http://unitsofmeasure.org",
            "code" : "%"
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    },
    {
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        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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          "display" : "Outpatient Surgery Physician/Surgical Services"
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      },
      "benefit" : [{
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            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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        "cost" : [{
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "No Charge after deductible"
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          {
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
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          "type" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
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              "display" : "In Network"
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              "display" : "In network, tier 1"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "After deductible"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "counts-toward-maximum",
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          "value" : {
            "value" : 0,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
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          "type" : {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
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            "text" : "Not stated"
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          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "display" : "In Network"
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          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 2"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          }],
          "value" : {
            "extension" : [{
              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay-percent",
              "display" : "Copayment Percent per service"
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            "text" : "Coinsurance"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "excluded-from-maximum",
              "display" : "Does not count toward the out-of-pocket maximum"
            }]
          }],
          "value" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
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        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "imaging",
          "display" : "Imaging (CT/PET/MRI)"
        },
        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
          "code" : "Imaging (CT/PET Scans, MRIs)",
          "display" : "Imaging (CT/PET Scans, MRIs)"
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      },
      "benefit" : [{
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            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "imaging",
            "display" : "Imaging (CT/PET/MRI)"
          },
          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
            "code" : "Imaging (CT/PET Scans, MRIs)",
            "display" : "Imaging (CT/PET Scans, MRIs)"
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        },
        "cost" : [{
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$250.00"
          }],
          "type" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
            }],
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
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          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "tier-1",
              "display" : "In network, tier 1"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "counts-toward-maximum",
              "display" : "Counts toward the out-of-pocket maximum"
            }]
          }],
          "value" : {
            "value" : 250,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
            "code" : "USD"
          }
        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$500.00"
          }],
          "type" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
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          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "tier-2",
              "display" : "In network, tier 2"
            }]
          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Counts toward the out-of-pocket maximum"
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          "value" : {
            "value" : 500,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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          }
        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
          }],
          "type" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay-percent",
              "display" : "Copayment Percent per service"
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            "text" : "Coinsurance"
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          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "display" : "Out of Network"
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          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Does not count toward the out-of-pocket maximum"
            }]
          }],
          "value" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
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        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "rehabilitation",
          "display" : "Rehabilitation Services"
        },
        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
          "code" : "Rehabilitative Occupational and Rehabilitative Physical Therapy",
          "display" : "Rehabilitative Occupational and Rehabilitative Physical Therapy"
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      "benefit" : [{
        "extension" : [{
          "extension" : [{
            "url" : "limitText",
            "valueString" : "Combined limit for all outpatient therapy plus chiropractic."
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          "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
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          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$70.00"
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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            "text" : "Copayment"
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          },
          {
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
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            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$70.00 Copay after deductible"
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          {
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
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          "type" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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            "text" : "Copayment"
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "tier-2",
              "display" : "In network, tier 2"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "After deductible"
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          },
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Counts toward the out-of-pocket maximum"
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          }],
          "value" : {
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            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay-percent",
              "display" : "Copayment Percent per service"
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            "text" : "Coinsurance"
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          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "display" : "Out of Network"
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          },
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
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        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
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        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
          "code" : "Mental/Behavioral Health Outpatient Services",
          "display" : "Mental/Behavioral Health Outpatient Services"
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            "url" : "limitText",
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          "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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        },
        "cost" : [{
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$35.00"
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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          },
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "tier-1",
              "display" : "In network, tier 1"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
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            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
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          "type" : {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
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            "text" : "Not stated"
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          "applicability" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "display" : "In Network"
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          },
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 2"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Counts toward the out-of-pocket maximum"
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          }],
          "value" : {
            "extension" : [{
              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
              "valueCode" : "unknown"
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          }
        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
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          "type" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment Percent per service"
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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          },
          "qualifiers" : [{
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
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        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
          "code" : "Emergency Transportation/Ambulance",
          "display" : "Emergency Transportation/Ambulance"
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      },
      "benefit" : [{
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            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "display" : "Emergency Transportation/Ambulance"
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        },
        "cost" : [{
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$200.00"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
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          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 1"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Counts toward the out-of-pocket maximum"
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          "value" : {
            "value" : 200,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
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          "type" : {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
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            "text" : "Not stated"
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          "applicability" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 2"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "Counts toward the out-of-pocket maximum"
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          }],
          "value" : {
            "extension" : [{
              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
              "valueCode" : "unknown"
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          }
        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$200.00"
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            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay",
              "display" : "Copayment per service"
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            "text" : "Copayment"
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            "coding" : [{
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            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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          "value" : {
            "value" : 200,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
            "code" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
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        {
          "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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          "display" : "Skilled Nursing Facility"
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      },
      "benefit" : [{
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            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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          {
            "system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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            "display" : "Skilled Nursing Facility"
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        },
        "cost" : [{
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            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "$250.00 Copay per Day after deductible"
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          {
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
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          "type" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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              "display" : "Copayment per service"
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            "text" : "Copayment"
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              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
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              "display" : "In Network"
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          },
          "qualifiers" : [{
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              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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              "display" : "In network, tier 1"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "per-day",
              "display" : "Per day"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "after-deductible",
              "display" : "After deductible"
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          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "counts-toward-maximum",
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          "value" : {
            "value" : 250,
            "unit" : "USD",
            "system" : "urn:iso:std:iso:4217",
            "code" : "USD"
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        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "Not Applicable"
          }],
          "type" : {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
              "code" : "not-stated",
              "display" : "Not stated"
            }],
            "text" : "Not stated"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "tier-2",
              "display" : "In network, tier 2"
            }]
          },
          {
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "counts-toward-maximum",
              "display" : "Counts toward the out-of-pocket maximum"
            }]
          }],
          "value" : {
            "extension" : [{
              "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
              "valueCode" : "unknown"
            }]
          }
        },
        {
          "extension" : [{
            "url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
            "valueString" : "100.00%"
          }],
          "type" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
              "code" : "copay-percent",
              "display" : "Copayment Percent per service"
            }],
            "text" : "Coinsurance"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
              "code" : "excluded-from-maximum",
              "display" : "Does not count toward the out-of-pocket maximum"
            }]
          }],
          "value" : {
            "value" : 100,
            "unit" : "%",
            "system" : "http://unitsofmeasure.org",
            "code" : "%"
          }
        }]
      }]
    }]
  }]
}