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: Plan Benefits: ACA Marketplace plan 19898FL0340001-01 - XML Representation

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<InsurancePlan xmlns="http://hl7.org/fhir">
  <id value="19898FL0340001-01"/>
  <meta>
    <profile
             value="https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan"/>
    <profile
             value="http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </text>
  <contained>
    <Organization>
      <id value="issuer"/>
      <identifier>
        <type>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/payor-identifier-types-cs"/>
            <code value="hios-id"/>
            <display value="Health Insurance Oversight System"/>
          </coding>
        </type>
        <system value="https://haau3.com/fhir/NamingSystem/hios-issuer-id"/>
        <value value="19898"/>
      </identifier>
      <name value="AvMed"/>
    </Organization>
  </contained>
  <contained>
    <Organization>
      <id value="network"/>
      <name value="AvMed HIX Network"/>
    </Organization>
  </contained>
  <contained>
    <Location>
      <id value="state-FL"/>
      <address>
        <state value="FL"/>
      </address>
      <physicalType>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/location-physical-type"/>
          <code value="jdn"/>
          <display value="Jurisdiction"/>
        </coding>
      </physicalType>
    </Location>
  </contained>
  <extension
             url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release">
    <extension url="release">
      <valueString value="aca-2026-2026-08-10"/>
    </extension>
    <extension url="file">
      <extension url="downloadUrl">
        <valueUri
                  value="https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip"/>
      </extension>
      <extension url="lastModified">
        <valueDate value="2026-08-10"/>
      </extension>
      <extension url="sha256">
        <valueString
                     value="954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2"/>
      </extension>
    </extension>
    <extension url="file">
      <extension url="downloadUrl">
        <valueUri
                  value="https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip"/>
      </extension>
      <extension url="lastModified">
        <valueDate value="2026-08-10"/>
      </extension>
      <extension url="sha256">
        <valueString
                     value="aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682"/>
      </extension>
    </extension>
    <extension url="file">
      <extension url="downloadUrl">
        <valueUri
                  value="https://download.cms.gov/marketplace-puf/2026/network-puf.zip"/>
      </extension>
      <extension url="lastModified">
        <valueDate value="2026-08-10"/>
      </extension>
      <extension url="sha256">
        <valueString
                     value="3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3"/>
      </extension>
    </extension>
    <extension url="file">
      <extension url="downloadUrl">
        <valueUri
                  value="https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip"/>
      </extension>
      <extension url="lastModified">
        <valueDate value="2026-08-10"/>
      </extension>
      <extension url="sha256">
        <valueString
                     value="eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f"/>
      </extension>
    </extension>
  </extension>
  <extension
             url="https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts">
    <extension url="metalLevel">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type"/>
          <code value="gold"/>
          <display value="Gold-QHP"/>
        </coding>
        <text value="Gold"/>
      </valueCodeableConcept>
    </extension>
    <extension url="csrVariation">
      <valueString value="Standard Gold On Exchange Plan"/>
    </extension>
    <extension url="market">
      <valueString value="Individual"/>
    </extension>
    <extension url="hsaEligible">
      <valueBoolean value="false"/>
    </extension>
    <extension url="effectiveDate">
      <valueDate value="2026-01-01"/>
    </extension>
    <extension url="enrollmentEnd">
      <valueDate value="2026-12-31"/>
    </extension>
    <extension url="outOfServiceAreaCoverage">
      <valueBoolean value="true"/>
    </extension>
    <extension url="outOfServiceAreaDescription">
      <valueString value="Emergency Only"/>
    </extension>
    <extension url="outOfCountryCoverage">
      <valueBoolean value="true"/>
    </extension>
    <extension url="outOfCountryDescription">
      <valueString value="Emergency Only"/>
    </extension>
    <extension url="multipleInNetworkTiers">
      <valueBoolean value="true"/>
    </extension>
    <extension url="deductiblesIntegrated">
      <valueBoolean value="true"/>
    </extension>
    <extension url="maximumIntegrated">
      <valueBoolean value="true"/>
    </extension>
    <extension url="primaryCareVisitsBeforeCostSharing">
      <valueUnsignedInt value="0"/>
    </extension>
    <extension url="primaryCareCopaysBeforeDeductible">
      <valueUnsignedInt value="0"/>
    </extension>
    <extension url="inpatientCopayMaxDays">
      <valueUnsignedInt value="0"/>
    </extension>
  </extension>
  <identifier>
    <system value="https://haau3.com/fhir/NamingSystem/hios-plan-id"/>
    <value value="19898FL0340001-01"/>
  </identifier>
  <identifier>
    <system
            value="https://haau3.com/fhir/NamingSystem/hios-standard-component-id"/>
    <value value="19898FL0340001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/insurance-product-type"/>
      <code value="qhp"/>
      <display value="Qualified Health Plan"/>
    </coding>
  </type>
  <name value="AvMed Entrust Gold 125 (2026)"/>
  <period>
    <start value="2026"/>
    <end value="2026"/>
  </period>
  <ownedBy>
    <reference value="#issuer"/>
    <display value="AvMed"/>
  </ownedBy>
  <coverageArea>
    <reference value="#state-FL"/>
  </coverageArea>
  <contact>
    <extension
               url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
      <valueCode value="unknown"/>
    </extension>
    <purpose>
      <text value="General Questions"/>
    </purpose>
  </contact>
  <contact>
    <purpose>
      <text value="Provider directory"/>
    </purpose>
    <telecom>
      <system value="url"/>
      <value
             value="https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&amp;brandCode=AVMED"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <text value="Summary of Benefits and Coverage"/>
    </purpose>
    <telecom>
      <system value="url"/>
      <value
             value="https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <text value="Plan brochure"/>
    </purpose>
    <telecom>
      <system value="url"/>
      <value
             value="https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf"/>
    </telecom>
  </contact>
  <contact>
    <purpose>
      <text value="Drug list"/>
    </purpose>
    <telecom>
      <system value="url"/>
      <value
             value="https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf"/>
    </telecom>
  </contact>
  <network>
    <reference value="#network"/>
    <display value="AvMed HIX Network"/>
  </network>
  <coverage>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
        <code value="HIP"/>
        <display value="health insurance plan policy"/>
      </coding>
    </type>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="primary-care-visit"/>
          <display value="Primary Care Visit"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Primary Care Visit to Treat an Injury or Illness"/>
          <display value="Primary Care Visit to Treat an Injury or Illness"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="specialist-visit"/>
          <display value="Specialist Visit"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Specialist Visit"/>
          <display value="Specialist Visit"/>
        </coding>
      </type>
      <requirement
                   value="Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care."/>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="urgent-care"/>
          <display value="Urgent Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Urgent Care Centers or Facilities"/>
          <display value="Urgent Care Centers or Facilities"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="emergency-room-care"/>
          <display value="Emergency Room Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Emergency Room Services"/>
          <display value="Emergency Room Services"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="hospital-inpatient"/>
          <display value="Hospital Inpatient Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
          <display value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="facility-fee"/>
          <display value="Facility Fee"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code
                value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
          <display
                   value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="physician-surgeon-fee"/>
          <display value="Physician/Surgeon Fees"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Outpatient Surgery Physician/Surgical Services"/>
          <display value="Outpatient Surgery Physician/Surgical Services"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="imaging"/>
          <display value="Imaging (CT/PET/MRI)"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Imaging (CT/PET Scans, MRIs)"/>
          <display value="Imaging (CT/PET Scans, MRIs)"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="rehabilitation"/>
          <display value="Rehabilitation Services"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code
                value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
          <display
                   value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="mental-health-outpatient"/>
          <display value="Mental/Behavioral Health Outpatient Services"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Mental/Behavioral Health Outpatient Services"/>
          <display value="Mental/Behavioral Health Outpatient Services"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="emergency-medical-transport"/>
          <display value="Emergency Medical Transportation"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Emergency Transportation/Ambulance"/>
          <display value="Emergency Transportation/Ambulance"/>
        </coding>
      </type>
    </benefit>
    <benefit>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="skilled-nursing"/>
          <display value="Skilled Nursing Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Skilled Nursing Facility"/>
          <display value="Skilled Nursing Facility"/>
        </coding>
      </type>
    </benefit>
  </coverage>
  <plan>
    <extension
               url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
      <extension url="category">
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Laboratory Outpatient and Professional Services"/>
            <display value="Laboratory Outpatient and Professional Services"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="$10.00"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="10"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </valueQuantity>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="Not Applicable"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </valueQuantity>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="100.00%"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </valueQuantity>
        </extension>
      </extension>
    </extension>
    <extension
               url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
      <extension url="category">
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code
                  value="Other Practitioner Office Visit (Nurse, Physician Assistant)"/>
            <display
                     value="Other Practitioner Office Visit (Nurse, Physician Assistant)"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="$35.00"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="35"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </valueQuantity>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="Not Applicable"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </valueQuantity>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="100.00%"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </valueQuantity>
        </extension>
      </extension>
    </extension>
    <extension
               url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
      <extension url="category">
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Home Health Care Services"/>
            <display value="Home Health Care Services"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="$70.00 Copay after deductible"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="70"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </valueQuantity>
        </extension>
        <extension url="deductibleApplies">
          <valueBoolean value="true"/>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="Not Applicable"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </valueQuantity>
        </extension>
      </extension>
      <extension url="cost">
        <extension
                   url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
          <valueString value="100.00%"/>
        </extension>
        <extension url="type">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </valueCodeableConcept>
        </extension>
        <extension url="applicability">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="qualifier">
          <valueCodeableConcept>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="amount">
          <valueQuantity>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </valueQuantity>
        </extension>
      </extension>
    </extension>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type"/>
        <code value="HMO"/>
        <display value="Health Maintenance Organization (HMO)"/>
      </coding>
      <text value="HMO"/>
    </type>
    <coverageArea>
      <reference value="#state-FL"/>
    </coverageArea>
    <generalCost>
      <type>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type"/>
          <code value="monthly-premium"/>
          <display value="Monthly premium"/>
        </coding>
        <text value="Monthly premium"/>
      </type>
      <comment
               value="Depends on age and where you live; not in these files."/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$2,000"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Individual Deductible"/>
      </type>
      <cost>
        <value value="2000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$2000 per person"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible (per person)"/>
      </type>
      <cost>
        <value value="2000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$4000 per group"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible"/>
      </type>
      <cost>
        <value value="4000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$2,000"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Individual Deductible"/>
      </type>
      <cost>
        <value value="2000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$2000 per person"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible (per person)"/>
      </type>
      <cost>
        <value value="2000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$4000 per group"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible"/>
      </type>
      <cost>
        <value value="4000"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="Not Applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Individual Deductible"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per person not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible (per person)"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per group not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="Not Applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Individual Deductible"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per person not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible (per person)"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per group not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Family Deductible"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$5,850"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Individual Out-of-Pocket Maximum"/>
      </type>
      <cost>
        <value value="5850"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$5850 per person"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum (per person)"/>
      </type>
      <cost>
        <value value="5850"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="in"/>
            <display value="In Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$11700 per group"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum"/>
      </type>
      <cost>
        <value value="11700"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 1, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$5,850"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Individual Out-of-Pocket Maximum"/>
      </type>
      <cost>
        <value value="5850"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$5850 per person"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum (per person)"/>
      </type>
      <cost>
        <value value="5850"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="tier-2"/>
            <display value="In network, tier 2"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="$11700 per group"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum"/>
      </type>
      <cost>
        <value value="11700"/>
        <currency value="USD"/>
      </cost>
      <comment value="In network tier 2, for medical care and drugs"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="Not Applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Individual Out-of-Pocket Maximum"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per person not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum (per person)"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
            <code value="out"/>
            <display value="Out of Network"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per group not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum"/>
      </type>
      <comment
               value="Out of network, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
            <display value="Individual"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="Not Applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Individual Out-of-Pocket Maximum"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="family-per-person"/>
            <display value="Family, per person"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per person not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum (per person)"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <generalCost>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
        <extension url="network">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="combined"/>
            <display value="In and out of network combined"/>
          </valueCoding>
        </extension>
        <extension url="member">
          <valueCoding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="family"/>
            <display value="Family"/>
          </valueCoding>
        </extension>
        <extension url="appliesTo">
          <valueCoding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
            <code value="medical-and-drug"/>
            <display value="Medical and drugs"/>
          </valueCoding>
        </extension>
      </extension>
      <extension
                 url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
        <valueString value="per group not applicable"/>
      </extension>
      <type>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
          <code value="maxoutofpocket"/>
          <display value="Maximum out of pocket"/>
        </coding>
        <text value="Family Out-of-Pocket Maximum"/>
      </type>
      <comment
               value="In and out of network combined, for medical care and drugs: not stated"/>
    </generalCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="primary-care-visit"/>
          <display value="Primary Care Visit"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Primary Care Visit to Treat an Injury or Illness"/>
          <display value="Primary Care Visit to Treat an Injury or Illness"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="primary-care-visit"/>
            <display value="Primary Care Visit"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Primary Care Visit to Treat an Injury or Illness"/>
            <display
                     value="Primary Care Visit to Treat an Injury or Illness"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$35.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="35"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="specialist-visit"/>
          <display value="Specialist Visit"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Specialist Visit"/>
          <display value="Specialist Visit"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="specialist-visit"/>
            <display value="Specialist Visit"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Specialist Visit"/>
            <display value="Specialist Visit"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$70.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="70"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="urgent-care"/>
          <display value="Urgent Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Urgent Care Centers or Facilities"/>
          <display value="Urgent Care Centers or Facilities"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="urgent-care"/>
            <display value="Urgent Care"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Urgent Care Centers or Facilities"/>
            <display value="Urgent Care Centers or Facilities"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$125.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="125"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$250.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="250"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$250.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="250"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="emergency-room-care"/>
          <display value="Emergency Room Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Emergency Room Services"/>
          <display value="Emergency Room Services"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="emergency-room-care"/>
            <display value="Emergency Room Care"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Emergency Room Services"/>
            <display value="Emergency Room Services"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$500.00 Copay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="500"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$500.00 Copay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="500"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="hospital-inpatient"/>
          <display value="Hospital Inpatient Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
          <display value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="hospital-inpatient"/>
            <display value="Hospital Inpatient Care"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
            <display
                     value="Inpatient Hospital Services (e.g., Hospital Stay)"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$850.00 Copay per Stay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="per-stay"/>
              <display value="Per stay"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="850"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="facility-fee"/>
          <display value="Facility Fee"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code
                value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
          <display
                   value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="facility-fee"/>
            <display value="Facility Fee"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code
                  value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
            <display
                     value="Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$650.00 Copay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="650"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$650.00 Copay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="650"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="physician-surgeon-fee"/>
          <display value="Physician/Surgeon Fees"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Outpatient Surgery Physician/Surgical Services"/>
          <display value="Outpatient Surgery Physician/Surgical Services"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="physician-surgeon-fee"/>
            <display value="Physician/Surgeon Fees"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Outpatient Surgery Physician/Surgical Services"/>
            <display value="Outpatient Surgery Physician/Surgical Services"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="No Charge after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="0"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="imaging"/>
          <display value="Imaging (CT/PET/MRI)"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Imaging (CT/PET Scans, MRIs)"/>
          <display value="Imaging (CT/PET Scans, MRIs)"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="imaging"/>
            <display value="Imaging (CT/PET/MRI)"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Imaging (CT/PET Scans, MRIs)"/>
            <display value="Imaging (CT/PET Scans, MRIs)"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$250.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="250"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$500.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="500"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="rehabilitation"/>
          <display value="Rehabilitation Services"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code
                value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
          <display
                   value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
        </coding>
      </category>
      <benefit>
        <extension
                   url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
          <extension url="limitText">
            <valueString
                         value="Combined limit for all outpatient therapy plus chiropractic."/>
          </extension>
        </extension>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="rehabilitation"/>
            <display value="Rehabilitation Services"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code
                  value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
            <display
                     value="Rehabilitative Occupational and Rehabilitative Physical Therapy"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$70.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="70"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$70.00 Copay after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="70"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="mental-health-outpatient"/>
          <display value="Mental/Behavioral Health Outpatient Services"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Mental/Behavioral Health Outpatient Services"/>
          <display value="Mental/Behavioral Health Outpatient Services"/>
        </coding>
      </category>
      <benefit>
        <extension
                   url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
          <extension url="limitText">
            <valueString
                         value="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."/>
          </extension>
        </extension>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="mental-health-outpatient"/>
            <display value="Mental/Behavioral Health Outpatient Services"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Mental/Behavioral Health Outpatient Services"/>
            <display value="Mental/Behavioral Health Outpatient Services"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$35.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="35"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="emergency-medical-transport"/>
          <display value="Emergency Medical Transportation"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Emergency Transportation/Ambulance"/>
          <display value="Emergency Transportation/Ambulance"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="emergency-medical-transport"/>
            <display value="Emergency Medical Transportation"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Emergency Transportation/Ambulance"/>
            <display value="Emergency Transportation/Ambulance"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$200.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="200"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$200.00"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="200"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
          <code value="skilled-nursing"/>
          <display value="Skilled Nursing Care"/>
        </coding>
        <coding>
          <system
                  value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
          <code value="Skilled Nursing Facility"/>
          <display value="Skilled Nursing Facility"/>
        </coding>
      </category>
      <benefit>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
            <code value="skilled-nursing"/>
            <display value="Skilled Nursing Care"/>
          </coding>
          <coding>
            <system
                    value="https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name"/>
            <code value="Skilled Nursing Facility"/>
            <display value="Skilled Nursing Facility"/>
          </coding>
        </type>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="$250.00 Copay per Day after deductible"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies">
            <valueBoolean value="true"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay"/>
              <display value="Copayment per service"/>
            </coding>
            <text value="Copayment"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-1"/>
              <display value="In network, tier 1"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="per-day"/>
              <display value="Per day"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="after-deductible"/>
              <display value="After deductible"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="250"/>
            <unit value="USD"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="Not Applicable"/>
          </extension>
          <type>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type"/>
              <code value="not-stated"/>
              <display value="Not stated"/>
            </coding>
            <text value="Not stated"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="tier-2"/>
              <display value="In network, tier 2"/>
            </coding>
          </qualifiers>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="counts-toward-maximum"/>
              <display value="Counts toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
              <valueCode value="unknown"/>
            </extension>
          </value>
        </cost>
        <cost>
          <extension
                     url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text">
            <valueString value="100.00%"/>
          </extension>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
              <code value="copay-percent"/>
              <display value="Copayment Percent per service"/>
            </coding>
            <text value="Coinsurance"/>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="out-of-network"/>
              <display value="Out of Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <coding>
              <system
                      value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
              <code value="excluded-from-maximum"/>
              <display
                       value="Does not count toward the out-of-pocket maximum"/>
            </coding>
          </qualifiers>
          <value>
            <value value="100"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="%"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
  </plan>
</InsurancePlan>