{
  "resourceType": "Bundle",
  "id": "bps-scan-classic-hmo-los-angeles",
  "type": "collection",
  "entry": [
    {
      "fullUrl": "urn:uuid:1abed8b9-5658-5ab6-a322-b23b689099e0",
      "resource": {
        "resourceType": "InsurancePlan",
        "id": "scan-classic-hmo-los-angeles",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan"
          ]
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>SCAN Classic (HMO)</b></p><p>Carrier: SCAN Health Plan. Plan type: HMO. Period: 2026-01-01 to 2026-12-31.</p><p>22 benefits are placed in CARIN SBC benefit categories. 49 benefits have no code in the SBC benefit category code system and are listed, by identity only, in the bps-unmapped-benefit extension.</p><p>Converted from Benefit Plan Standard document SCAN_CLASSIC_HMO_LOS_ANGELES (schema version 1.2.0).</p></div>"
        },
        "extension": [
          {
            "extension": [
              {
                "url": "schemaVersion",
                "valueString": "1.2.0"
              },
              {
                "url": "planYear",
                "valueInteger": 2026
              },
              {
                "url": "market",
                "valueString": "medicare_advantage"
              },
              {
                "url": "serviceAreaState",
                "valueString": "CA"
              },
              {
                "url": "serviceAreaCounty",
                "valueString": "Los Angeles"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-plan-metadata"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 1
              },
              {
                "url": "excerpt",
                "valueString": "2026 Summary of Benefits | SCAN Classic (HMO) | SCAN Prime (HMO) | Los Angeles County | January 1, 2026 – December 31, 2026"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 1
              },
              {
                "url": "excerpt",
                "valueString": "SCAN Classic (HMO) and SCAN Prime (HMO) are HMO plans with Medicare contracts. | Y0057_SCAN_21986_2026_M | 8/25 26C-SBH5425006065"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 3
              },
              {
                "url": "excerpt",
                "valueString": "Monthly Health Plan Premium | SCAN Classic: $0 | What you should know: You must continue to pay your Medicare Part B premium."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 3
              },
              {
                "url": "excerpt",
                "valueString": "Plan Deductible | SCAN Classic: No deductible for medical. See outpatient prescription drugs section for Part D deductible."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 3
              },
              {
                "url": "excerpt",
                "valueString": "Maximum Out-of-Pocket Responsibility (this does not include prescription drugs) | SCAN Classic: $199 | What you should know: The most you pay for copays and coinsurance for Medicare-covered medical services for the year."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 8
              },
              {
                "url": "excerpt",
                "valueString": "OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS): SCAN CLASSIC | Part D Deductible | You pay the full cost of your Tier 3 through Tier 5 drugs until you have paid $250."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 9
              },
              {
                "url": "excerpt",
                "valueString": "Catastrophic Coverage Stage | After your yearly out-of-pocket drug costs reach $2,100, you pay $0 for all covered prescription drugs for the remainder of the year."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 9
              },
              {
                "url": "excerpt",
                "valueString": "Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs if you use these pharmacies."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 9
              },
              {
                "url": "excerpt",
                "valueString": "If you reside in a long-term care facility, your cost-sharing for a 31-day supply is the same as at a standard retail pharmacy for a 30-day supply. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 17
              },
              {
                "url": "excerpt",
                "valueString": "Who can join? | live in the plan service area (Los Angeles County, California)"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 17
              },
              {
                "url": "excerpt",
                "valueString": "SCAN Classic and SCAN Prime have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 4
              },
              {
                "url": "excerpt",
                "valueString": "Emergency Care | What you should know: You are covered for worldwide emergency services at Original Medicare reimbursable rates."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 6
              },
              {
                "url": "excerpt",
                "valueString": "*A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven't received any inpatient hospital or SNF care for 60 days in a row."
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "pageNumber",
                "valueInteger": 16
              },
              {
                "url": "excerpt",
                "valueString": "OPTIONAL SUPPLEMENTAL BENEFITS | DENTAL SERVICES | SCAN CLASSIC | PPO Dental Plan California | Monthly Premium | $55 per month"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "OUTPATIENT_HOSPITAL"
              },
              {
                "url": "serviceName",
                "valueString": "Outpatient hospital services"
              },
              {
                "url": "category",
                "valueString": "HOSPITAL_SERVICES"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "OBSERVATION"
              },
              {
                "url": "canonicalKey",
                "valueString": "observation_care"
              },
              {
                "url": "serviceName",
                "valueString": "Observation services"
              },
              {
                "url": "category",
                "valueString": "HOSPITAL_SERVICES"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "THERAPEUTIC_RADIOLOGY"
              },
              {
                "url": "canonicalKey",
                "valueString": "radiation_therapy"
              },
              {
                "url": "serviceName",
                "valueString": "Therapeutic radiology"
              },
              {
                "url": "category",
                "valueString": "RADIATION_THERAPY"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HEARING_EXAM_MEDICARE"
              },
              {
                "url": "serviceName",
                "valueString": "Diagnostic hearing and balance exam (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "HEARING"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HEARING_EXAM_ROUTINE"
              },
              {
                "url": "serviceName",
                "valueString": "Routine hearing exam"
              },
              {
                "url": "category",
                "valueString": "HEARING"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HEARING_AID_ADVANCED"
              },
              {
                "url": "serviceName",
                "valueString": "Hearing aid, TruHearing Advanced"
              },
              {
                "url": "category",
                "valueString": "HEARING"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HEARING_AID_PREMIUM"
              },
              {
                "url": "serviceName",
                "valueString": "Hearing aid, TruHearing Premium"
              },
              {
                "url": "category",
                "valueString": "HEARING"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_MEDICARE"
              },
              {
                "url": "serviceName",
                "valueString": "Dental services (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_EXAMS"
              },
              {
                "url": "serviceName",
                "valueString": "Routine dental exams"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_CLEANINGS"
              },
              {
                "url": "serviceName",
                "valueString": "Routine dental cleanings"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_XRAYS"
              },
              {
                "url": "serviceName",
                "valueString": "Routine dental X-rays"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_DIAGNOSTIC"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: diagnostic services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_PREVENTIVE"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: preventive services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_RESTORATIVE"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: restorative services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_ENDODONTIC"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: endodontic services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_PERIODONTIC"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: periodontics"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_PROSTHODONTIC_REMOVABLE"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: removable prosthodontics"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_PROSTHODONTIC_FIXED"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: fixed prosthodontics"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_ORAL_SURGERY"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: oral and maxillofacial surgery"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_ADJUNCTIVE"
              },
              {
                "url": "serviceName",
                "valueString": "Comprehensive dental: adjunctive services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_MAXILLOFACIAL_PROSTHETICS"
              },
              {
                "url": "serviceName",
                "valueString": "Maxillofacial prosthetics"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DENTAL_IMPLANTS"
              },
              {
                "url": "serviceName",
                "valueString": "Dental implant services"
              },
              {
                "url": "category",
                "valueString": "DENTAL"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "VISION_EXAM_MEDICARE"
              },
              {
                "url": "serviceName",
                "valueString": "Eye exam to diagnose or treat eye disease (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "VISION"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "EYEWEAR_POST_CATARACT"
              },
              {
                "url": "serviceName",
                "valueString": "Glasses after cataract surgery (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "VISION"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "VISION_EXAM_ROUTINE"
              },
              {
                "url": "serviceName",
                "valueString": "Routine vision exam"
              },
              {
                "url": "category",
                "valueString": "VISION"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "EYEWEAR_ROUTINE"
              },
              {
                "url": "serviceName",
                "valueString": "Routine eyewear allowance"
              },
              {
                "url": "category",
                "valueString": "VISION"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "TRANSPORTATION_ROUTINE"
              },
              {
                "url": "serviceName",
                "valueString": "Routine transportation"
              },
              {
                "url": "category",
                "valueString": "TRANSPORTATION"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "PART_B_DRUGS"
              },
              {
                "url": "serviceName",
                "valueString": "Medicare Part B drugs, including chemotherapy"
              },
              {
                "url": "category",
                "valueString": "PART_B_DRUGS"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "PART_B_INSULIN"
              },
              {
                "url": "serviceName",
                "valueString": "Part B insulin furnished through durable medical equipment"
              },
              {
                "url": "category",
                "valueString": "PART_B_DRUGS"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "RX_TIER3_INSULIN"
              },
              {
                "url": "serviceName",
                "valueString": "Tier 3 insulin"
              },
              {
                "url": "category",
                "valueString": "PHARMACY"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "RX_TIER4"
              },
              {
                "url": "serviceName",
                "valueString": "Tier 4 non-preferred drugs"
              },
              {
                "url": "category",
                "valueString": "PHARMACY"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "PART_D_VACCINES"
              },
              {
                "url": "serviceName",
                "valueString": "Most adult Part D vaccines"
              },
              {
                "url": "category",
                "valueString": "PHARMACY"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "ACUPUNCTURE_MEDICARE"
              },
              {
                "url": "canonicalKey",
                "valueString": "acupuncture"
              },
              {
                "url": "serviceName",
                "valueString": "Acupuncture (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "ACUPUNCTURE"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "ACUPUNCTURE_ROUTINE"
              },
              {
                "url": "canonicalKey",
                "valueString": "acupuncture"
              },
              {
                "url": "serviceName",
                "valueString": "Routine acupuncture"
              },
              {
                "url": "category",
                "valueString": "ACUPUNCTURE"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "IN_HOME_CARE"
              },
              {
                "url": "serviceName",
                "valueString": "Personal in-home care"
              },
              {
                "url": "category",
                "valueString": "IN_HOME_SUPPORT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "MEALS_POST_HOSPITAL"
              },
              {
                "url": "serviceName",
                "valueString": "Home-delivered meals after a hospitalization"
              },
              {
                "url": "category",
                "valueString": "MEALS"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "MEALS_CHRONIC_CONDITION"
              },
              {
                "url": "serviceName",
                "valueString": "Home-delivered meals for a chronic condition"
              },
              {
                "url": "category",
                "valueString": "MEALS"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "RESPITE_CARE"
              },
              {
                "url": "serviceName",
                "valueString": "Respite care"
              },
              {
                "url": "category",
                "valueString": "IN_HOME_SUPPORT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "CHIROPRACTIC_MEDICARE"
              },
              {
                "url": "canonicalKey",
                "valueString": "chiropractic_care"
              },
              {
                "url": "serviceName",
                "valueString": "Chiropractic care (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "CHIROPRACTIC"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "CHIROPRACTIC_ROUTINE"
              },
              {
                "url": "canonicalKey",
                "valueString": "chiropractic_care"
              },
              {
                "url": "serviceName",
                "valueString": "Routine chiropractic care"
              },
              {
                "url": "category",
                "valueString": "CHIROPRACTIC"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "OTC_ALLOWANCE"
              },
              {
                "url": "serviceName",
                "valueString": "Over-the-counter products allowance (FlexEssentials)"
              },
              {
                "url": "category",
                "valueString": "OVER_THE_COUNTER"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HEALTHTECH"
              },
              {
                "url": "serviceName",
                "valueString": "Technology support (HEALTHtech+)"
              },
              {
                "url": "category",
                "valueString": "MEMBER_SUPPORT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "HOME_HEALTH_CARE"
              },
              {
                "url": "canonicalKey",
                "valueString": "home_health_care"
              },
              {
                "url": "serviceName",
                "valueString": "Home health care (Medicare-covered)"
              },
              {
                "url": "category",
                "valueString": "HOME_HEALTH"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "PROSTHETICS"
              },
              {
                "url": "canonicalKey",
                "valueString": "prosthetics"
              },
              {
                "url": "serviceName",
                "valueString": "Prosthetics"
              },
              {
                "url": "category",
                "valueString": "DURABLE_MEDICAL_EQUIPMENT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "DIABETIC_SUPPLIES"
              },
              {
                "url": "canonicalKey",
                "valueString": "diabetic_supplies"
              },
              {
                "url": "serviceName",
                "valueString": "Diabetic supplies"
              },
              {
                "url": "category",
                "valueString": "DURABLE_MEDICAL_EQUIPMENT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "CONTINUOUS_GLUCOSE_MONITORS"
              },
              {
                "url": "serviceName",
                "valueString": "Continuous glucose monitors"
              },
              {
                "url": "category",
                "valueString": "DURABLE_MEDICAL_EQUIPMENT"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "FITNESS"
              },
              {
                "url": "serviceName",
                "valueString": "Fitness benefit (One Pass)"
              },
              {
                "url": "category",
                "valueString": "FITNESS"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "PERSONAL_EMERGENCY_RESPONSE"
              },
              {
                "url": "serviceName",
                "valueString": "Personal emergency response system"
              },
              {
                "url": "category",
                "valueString": "PERSONAL_EMERGENCY_RESPONSE"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          },
          {
            "extension": [
              {
                "url": "benefitId",
                "valueString": "TELEHEALTH"
              },
              {
                "url": "canonicalKey",
                "valueString": "telehealth_visit"
              },
              {
                "url": "serviceName",
                "valueString": "Telehealth for urgent care and mental health"
              },
              {
                "url": "category",
                "valueString": "TELEHEALTH"
              }
            ],
            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit"
          }
        ],
        "identifier": [
          {
            "system": "https://benefitplanstandard.org/plan-id",
            "value": "SCAN_CLASSIC_HMO_LOS_ANGELES"
          },
          {
            "extension": [
              {
                "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-identifier-source",
                "valueString": "Public CMS-derived plan listings; the Summary of Benefits prints no contract and plan number for SCAN Classic (docs/medicare-advantage-notes.md, section 1)."
              }
            ],
            "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_plan_segment",
            "value": "H5425-006-0"
          },
          {
            "extension": [
              {
                "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-identifier-source",
                "valueString": "Public CMS-derived plan listings; the Summary of Benefits prints no contract and plan number for SCAN Classic (docs/medicare-advantage-notes.md, section 1)."
              }
            ],
            "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_id",
            "value": "H5425"
          },
          {
            "extension": [
              {
                "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-identifier-source",
                "valueString": "Public CMS-derived plan listings; the Summary of Benefits prints no contract and plan number for SCAN Classic (docs/medicare-advantage-notes.md, section 1)."
              }
            ],
            "system": "https://benefitplanstandard.org/fhir/identifier/cms_pbp_id",
            "value": "006"
          }
        ],
        "status": "active",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/insurance-plan-type",
                "code": "medical",
                "display": "Medical"
              }
            ]
          }
        ],
        "name": "SCAN Classic (HMO)",
        "period": {
          "start": "2026-01-01",
          "end": "2026-12-31"
        },
        "ownedBy": {
          "reference": "urn:uuid:584807d0-7e3b-5c6b-bd97-a1585e7c68bd",
          "display": "SCAN Health Plan"
        },
        "contact": [
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                "valueCode": "unknown"
              }
            ],
            "purpose": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/contactentity-type",
                  "code": "PAYOR",
                  "display": "Payor"
                }
              ]
            }
          }
        ],
        "coverage": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "hospital-inpatient",
                  "display": "Hospital Inpatient Care"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "INPATIENT_HOSPITAL"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "HOSPITAL_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Inpatient Hospital Coverage"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "inpatient_hospital"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules may apply."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 3
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Inpatient Hospital Coverage | SCAN Classic: $0 Unlimited days per admission | What you should know: Prior authorization rules may apply."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "facility-fee",
                      "display": "Facility Fee"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "inpatient_hospital",
                      "display": "Inpatient hospital"
                    }
                  ],
                  "text": "Inpatient hospital"
                },
                "requirement": "Prior authorization rules may apply."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "hospital-outpatient",
                  "display": "Hospital Outpatient Care"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "AMBULATORY_SURGICAL_CENTER"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "SURGICAL_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Ambulatory Surgical Center"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "ambulatory_surgery_center"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for outpatient hospital services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 3
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Outpatient Hospital Services > Ambulatory Surgical Center | SCAN Classic: $0 | What you should know: Prior authorization rules apply for outpatient hospital services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "facility-fee",
                      "display": "Facility Fee"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "outpatient_surgery_facility",
                      "display": "Outpatient surgery facility"
                    }
                  ],
                  "text": "Ambulatory surgical center"
                },
                "requirement": "Prior authorization rules apply for outpatient hospital services."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "primary-care-visit",
                  "display": "Primary Care Visit"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "PRIMARY_CARE"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "PHYSICIAN_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Primary Care"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "office"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 3
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Doctor Visits > Primary Care | SCAN Classic: $0"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "primary-care-visit",
                      "display": "Primary Care Visit"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "primary_care",
                      "display": "Primary care visit"
                    }
                  ],
                  "text": "Primary care visit"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "specialist-visit",
                  "display": "Specialist Visit"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "SPECIALIST"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "PHYSICIAN_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Specialists"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "office"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for specialist visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 3
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Doctor Visits > Specialists | SCAN Classic: $0 | What you should know: Prior authorization rules apply for specialist visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "specialist-visit",
                      "display": "Specialist Visit"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "specialist",
                      "display": "Specialist visit"
                    }
                  ],
                  "text": "Specialist visit"
                },
                "requirement": "Prior authorization rules apply for specialist visits."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "preventive-care",
                  "display": "Preventive Care/Screening/Immunization"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "PREVENTIVE_CARE"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "PREVENTIVE_CARE"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Preventive Care"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 3
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Preventive Care | SCAN Classic: $0 | What you should know: Prior authorization rules apply."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "preventive-care",
                      "display": "Preventive Care/Screening/Immunization"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "preventive_care",
                      "display": "Preventive care"
                    }
                  ],
                  "text": "Preventive care"
                },
                "requirement": "Prior authorization rules apply."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "emergency-room-care",
                  "display": "Emergency Room Care"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "EMERGENCY_ROOM"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "EMERGENCY_CARE"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Emergency Care"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "emergency_room"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Emergency Care | SCAN Classic: $90 copay per visit | What you should know: The emergency room copay will be waived if you are immediately admitted to the hospital. You are covered for worldwide emergency services at Original Medicare reimbursable rates."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "emergency-room-care",
                      "display": "Emergency Room Care"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "emergency_room",
                      "display": "Emergency room"
                    }
                  ],
                  "text": "Emergency care"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "urgent-care",
                  "display": "Urgent Care"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "URGENT_CARE"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "URGENT_CARE"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Urgently Needed Services"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Urgently Needed Services | SCAN Classic: $0 | What you should know: You are covered for worldwide urgent care services at Original Medicare reimbursable rates."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "urgent-care",
                      "display": "Urgent Care"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "urgent_care",
                      "display": "Urgent care"
                    }
                  ],
                  "text": "Urgently needed services"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "diagnostic-test",
                  "display": "Diagnostic Test"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "LAB_SERVICES"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "DIAGNOSTIC_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Lab services"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "laboratory"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Diagnostic Services/Labs/Imaging > Lab services | SCAN Classic: $0 | What you should know: Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "diagnostic-test",
                      "display": "Diagnostic Test"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "diagnostic_lab",
                      "display": "Diagnostic lab"
                    }
                  ],
                  "text": "Lab services"
                },
                "requirement": "Prior authorization rules apply for diagnostic, lab, and imaging services."
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "DIAGNOSTIC_TESTS"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "DIAGNOSTIC_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Diagnostic tests and procedures"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Diagnostic Services/Labs/Imaging > Diagnostic tests and procedures | SCAN Classic: $0 | What you should know: Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "diagnostic-test",
                      "display": "Diagnostic Test"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "diagnostic_test",
                      "display": "Diagnostic test"
                    }
                  ],
                  "text": "Diagnostic tests and procedures"
                },
                "requirement": "Prior authorization rules apply for diagnostic, lab, and imaging services."
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "OUTPATIENT_XRAYS"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "DIAGNOSTIC_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Outpatient X-rays"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Diagnostic Services/Labs/Imaging > Outpatient X-rays | SCAN Classic: $0 | What you should know: Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "diagnostic-test",
                      "display": "Diagnostic Test"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "imaging_standard",
                      "display": "Standard imaging"
                    }
                  ],
                  "text": "Outpatient X-rays"
                },
                "requirement": "Prior authorization rules apply for diagnostic, lab, and imaging services."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "imaging",
                  "display": "Imaging (CT/PET/MRI)"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "DIAGNOSTIC_RADIOLOGY"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "DIAGNOSTIC_SERVICES"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Diagnostic radiology (e.g., MRI, CT)"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 4
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Diagnostic Services/Labs/Imaging > Diagnostic radiology (e.g., MRI, CT) | SCAN Classic: $0 | What you should know: Prior authorization rules apply for diagnostic, lab, and imaging services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "imaging",
                      "display": "Imaging (CT/PET/MRI)"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "imaging_advanced",
                      "display": "Advanced imaging"
                    }
                  ],
                  "text": "Diagnostic radiology (MRI, CT)"
                },
                "requirement": "Prior authorization rules apply for diagnostic, lab, and imaging services."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "mental-health-inpatient",
                  "display": "Mental/Behavioral Health Inpatient Services"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "limitText",
                        "valueString": "You are covered for up to 90 days per benefit period.*"
                      },
                      {
                        "url": "limitType",
                        "valueCodeableConcept": {
                          "coding": [
                            {
                              "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type",
                              "code": "days",
                              "display": "Days"
                            }
                          ]
                        }
                      },
                      {
                        "url": "limitValue",
                        "valueQuantity": {
                          "value": 90,
                          "unit": "days"
                        }
                      },
                      {
                        "url": "limitPeriod",
                        "valueCodeableConcept": {
                          "coding": [
                            {
                              "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period",
                              "code": "benefit-period",
                              "display": "Benefit Period"
                            }
                          ]
                        }
                      }
                    ],
                    "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
                  },
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "MENTAL_HEALTH_INPATIENT"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "behavioral_health"
                      },
                      {
                        "url": "category",
                        "valueString": "BEHAVIORAL_HEALTH"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Inpatient visit"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for inpatient mental health hospitalization."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 6
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Mental Health Services > Inpatient visit | SCAN Classic: $0 per day for days 1-90 | What you should know: Prior authorization rules apply for inpatient mental health hospitalization. You are covered for up to 90 days per benefit period.*"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "mental-health-inpatient",
                      "display": "Mental/Behavioral Health Inpatient Services"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "mental_health_inpatient",
                      "display": "Mental health inpatient"
                    }
                  ],
                  "text": "Inpatient mental health"
                },
                "requirement": "Prior authorization rules apply for inpatient mental health hospitalization."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "mental-health-outpatient",
                  "display": "Mental/Behavioral Health Outpatient Services"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "MENTAL_HEALTH_OUTPATIENT"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "behavioral_health"
                      },
                      {
                        "url": "category",
                        "valueString": "BEHAVIORAL_HEALTH"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Outpatient individual/group therapy visit"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for outpatient individual/group therapy visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 6
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Mental Health Services > Outpatient individual/group therapy visit | SCAN Classic: $0 | What you should know: Prior authorization rules apply for outpatient individual/group therapy visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "mental-health-outpatient",
                      "display": "Mental/Behavioral Health Outpatient Services"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "mental_health_outpatient",
                      "display": "Mental health outpatient"
                    }
                  ],
                  "text": "Outpatient therapy visit"
                },
                "requirement": "Prior authorization rules apply for outpatient individual/group therapy visits."
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "MENTAL_HEALTH_OUTPATIENT_PSYCHIATRIST"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "behavioral_health"
                      },
                      {
                        "url": "category",
                        "valueString": "BEHAVIORAL_HEALTH"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Outpatient individual/group therapy visit with a psychiatrist"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for outpatient individual/group therapy visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 6
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Mental Health Services > Outpatient individual/group therapy visit with a psychiatrist | SCAN Classic: $0 | What you should know: Prior authorization rules apply for outpatient individual/group therapy visits."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "mental-health-outpatient",
                      "display": "Mental/Behavioral Health Outpatient Services"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "mental_health_outpatient",
                      "display": "Mental health outpatient"
                    }
                  ],
                  "text": "Outpatient therapy visit with a psychiatrist"
                },
                "requirement": "Prior authorization rules apply for outpatient individual/group therapy visits."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "skilled-nursing",
                  "display": "Skilled Nursing Care"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "limitText",
                        "valueString": "You are covered for up to 100 days per benefit period.*"
                      },
                      {
                        "url": "limitType",
                        "valueCodeableConcept": {
                          "coding": [
                            {
                              "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type",
                              "code": "days",
                              "display": "Days"
                            }
                          ]
                        }
                      },
                      {
                        "url": "limitValue",
                        "valueQuantity": {
                          "value": 100,
                          "unit": "days"
                        }
                      },
                      {
                        "url": "limitPeriod",
                        "valueCodeableConcept": {
                          "coding": [
                            {
                              "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period",
                              "code": "benefit-period",
                              "display": "Benefit Period"
                            }
                          ]
                        }
                      }
                    ],
                    "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
                  },
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "SKILLED_NURSING_FACILITY"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "SKILLED_NURSING"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Skilled Nursing Facility"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for skilled nursing facility services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "clinical"
                      },
                      {
                        "url": "description",
                        "valueString": "No prior hospitalization is required."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 6
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Skilled Nursing Facility | SCAN Classic: $0 for days 1-100 | What you should know: Prior authorization rules apply for skilled nursing facility services. You are covered for up to 100 days per benefit period.* No prior hospitalization is required."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "skilled-nursing",
                      "display": "Skilled Nursing Care"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "skilled_nursing_facility",
                      "display": "Skilled nursing facility"
                    }
                  ],
                  "text": "Skilled nursing facility"
                },
                "requirement": "Prior authorization rules apply for skilled nursing facility services.; No prior hospitalization is required."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "rehabilitation",
                  "display": "Rehabilitation Services"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "PHYSICAL_THERAPY"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "REHABILITATION"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Physical Therapy"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for outpatient physical therapy services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 7
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Physical Therapy | SCAN Classic: $0 | What you should know: Prior authorization rules apply for outpatient physical therapy services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "rehabilitation",
                      "display": "Rehabilitation Services"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "physical_therapy",
                      "display": "Physical therapy"
                    }
                  ],
                  "text": "Physical therapy"
                },
                "requirement": "Prior authorization rules apply for outpatient physical therapy services."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "emergency-medical-transport",
                  "display": "Emergency Medical Transportation"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "AMBULANCE"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "EMERGENCY_CARE"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Ambulance"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for non-emergency and air ambulance services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 7
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Ambulance | SCAN Classic: $200 copay per one-way trip | What you should know: Prior authorization rules apply for non-emergency and air ambulance services."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "emergency-medical-transport",
                      "display": "Emergency Medical Transportation"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "ambulance",
                      "display": "Ambulance services"
                    }
                  ],
                  "text": "Ambulance"
                },
                "requirement": "Prior authorization rules apply for non-emergency and air ambulance services."
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "generic-drugs",
                  "display": "Generic Drugs"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "RX_TIER1"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "category",
                        "valueString": "PHARMACY"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Tier 1 (Preferred Generic)"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "exclude"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 8
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Initial Coverage Stage | columns: Retail Preferred 30-day supply, Retail Preferred 100-day supply, Retail Standard 30-day supply, Retail Standard 100-day supply, Mail-Order Preferred 100-day supply, Mail-Order Standard 100-day supply | Tier 1 (Preferred Generic): $0 $0 $7 $14 $0 $14"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "generic-drugs",
                      "display": "Generic Drugs"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "preferred_generic_drugs",
                      "display": "Preferred generic drugs"
                    }
                  ],
                  "text": "Tier 1 preferred generic drugs"
                }
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "RX_TIER2"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "category",
                        "valueString": "PHARMACY"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Tier 2 (Generic)"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "exclude"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 8
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Initial Coverage Stage | columns: Retail Preferred 30-day supply, Retail Preferred 100-day supply, Retail Standard 30-day supply, Retail Standard 100-day supply, Mail-Order Preferred 100-day supply, Mail-Order Standard 100-day supply | Tier 2 (Generic): $0 $0 $15 $30 $0 $30"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "generic-drugs",
                      "display": "Generic Drugs"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "generic_drugs",
                      "display": "Generic drugs"
                    }
                  ],
                  "text": "Tier 2 generic drugs"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "preferred-brand-drugs",
                  "display": "Preferred Brand Drugs"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "RX_TIER3"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "category",
                        "valueString": "PHARMACY"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Tier 3 (Preferred Brand) Other Drugs"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "exclude"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 8
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Initial Coverage Stage | columns: Retail Preferred 30-day supply, Retail Preferred 100-day supply, Retail Standard 30-day supply, Retail Standard 100-day supply, Mail-Order Preferred 100-day supply, Mail-Order Standard 100-day supply | Tier 3 (Preferred Brand) Other Drugs: $42 $126 $47 $141 $126 $141"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "preferred-brand-drugs",
                      "display": "Preferred Brand Drugs"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "preferred_brand_drugs",
                      "display": "Preferred brand drugs"
                    }
                  ],
                  "text": "Tier 3 preferred brand drugs (other than insulin)"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "specialty-drugs",
                  "display": "Specialty Drugs"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "RX_TIER5"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "category",
                        "valueString": "PHARMACY"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Tier 5 (Specialty Tier)"
                      },
                      {
                        "url": "placeOfService",
                        "valueString": "pharmacy"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "exclude"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 8
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Initial Coverage Stage | columns: Retail Preferred 30-day supply, Retail Preferred 100-day supply, Retail Standard 30-day supply, Retail Standard 100-day supply, Mail-Order Preferred 100-day supply, Mail-Order Standard 100-day supply | Tier 5 (Specialty Tier): 30% Not available 30% Not available Not available Not available"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "specialty-drugs",
                      "display": "Specialty Drugs"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "specialty_drugs",
                      "display": "Specialty drugs"
                    }
                  ],
                  "text": "Tier 5 specialty drugs"
                }
              }
            ]
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                  "code": "durable-medical-equipment",
                  "display": "Durable Medical Equipment"
                }
              ]
            },
            "benefit": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "benefitId",
                        "valueString": "DURABLE_MEDICAL_EQUIPMENT"
                      },
                      {
                        "url": "benefitType",
                        "valueString": "medical"
                      },
                      {
                        "url": "category",
                        "valueString": "DURABLE_MEDICAL_EQUIPMENT"
                      },
                      {
                        "url": "rawLabel",
                        "valueString": "Durable Medical Equipment (e.g., wheelchairs, oxygen)"
                      },
                      {
                        "url": "moopApplicability",
                        "valueString": "plan_default"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit"
                  },
                  {
                    "extension": [
                      {
                        "url": "type",
                        "valueString": "authorization"
                      },
                      {
                        "url": "description",
                        "valueString": "Prior authorization rules apply for covered durable medical equipment, prosthetic devices, and certain diabetic supplies."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition"
                  },
                  {
                    "extension": [
                      {
                        "url": "pageNumber",
                        "valueInteger": 14
                      },
                      {
                        "url": "excerpt",
                        "valueString": "Medical Equipment/Supplies > Durable Medical Equipment (e.g., wheelchairs, oxygen) | SCAN Classic: $0 | What you should know: Prior authorization rules apply for covered durable medical equipment, prosthetic devices, and certain diabetic supplies."
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "durable-medical-equipment",
                      "display": "Durable Medical Equipment"
                    },
                    {
                      "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                      "code": "durable_medical_equipment",
                      "display": "Durable medical equipment"
                    }
                  ],
                  "text": "Durable medical equipment"
                },
                "requirement": "Prior authorization rules apply for covered durable medical equipment, prosthetic devices, and certain diabetic supplies."
              }
            ]
          }
        ],
        "plan": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type",
                  "code": "HMO",
                  "display": "Health Maintenance Organization (HMO)"
                }
              ]
            },
            "generalCost": [
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "slot",
                        "valueString": "individual_deductible"
                      },
                      {
                        "url": "networkTier",
                        "valueString": "in-network"
                      },
                      {
                        "url": "period",
                        "valueString": "per_year"
                      },
                      {
                        "url": "appliesTo",
                        "valueString": "medical"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                      "code": "deductible",
                      "display": "Deductible"
                    }
                  ],
                  "text": "Individual deductible, in-network"
                },
                "cost": {
                  "value": 0,
                  "currency": "USD"
                },
                "comment": "in-network; per_year"
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "slot",
                        "valueString": "individual_oop_max"
                      },
                      {
                        "url": "networkTier",
                        "valueString": "in-network"
                      },
                      {
                        "url": "period",
                        "valueString": "per_year"
                      },
                      {
                        "url": "appliesTo",
                        "valueString": "medical"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                      "code": "maxoutofpocket",
                      "display": "Maximum out of pocket"
                    }
                  ],
                  "text": "Individual out-of-pocket maximum, in-network"
                },
                "cost": {
                  "value": 199,
                  "currency": "USD"
                },
                "comment": "in-network; per_year"
              },
              {
                "type": {
                  "text": "Premium"
                },
                "cost": {
                  "value": 0,
                  "currency": "USD"
                },
                "comment": "per_month; You must continue to pay your Medicare Part B premium."
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "slot",
                        "valueString": "pharmacy.deductible"
                      },
                      {
                        "url": "period",
                        "valueString": "per_year"
                      },
                      {
                        "url": "appliesToTier",
                        "valueString": "Tier 3"
                      },
                      {
                        "url": "appliesToTier",
                        "valueString": "Tier 4"
                      },
                      {
                        "url": "appliesToTier",
                        "valueString": "Tier 5"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                      "code": "deductible",
                      "display": "Deductible"
                    }
                  ],
                  "text": "Pharmacy deductible"
                },
                "cost": {
                  "value": 250,
                  "currency": "USD"
                },
                "comment": "per_year; applies to Tier 3, Tier 4, Tier 5"
              },
              {
                "extension": [
                  {
                    "extension": [
                      {
                        "url": "slot",
                        "valueString": "pharmacy.out_of_pocket_max"
                      },
                      {
                        "url": "period",
                        "valueString": "per_year"
                      }
                    ],
                    "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator"
                  }
                ],
                "type": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                      "code": "maxoutofpocket",
                      "display": "Maximum out of pocket"
                    }
                  ],
                  "text": "Pharmacy out-of-pocket maximum"
                },
                "cost": {
                  "value": 2100,
                  "currency": "USD"
                },
                "comment": "per_year"
              }
            ],
            "specificCost": [
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "hospital-inpatient",
                      "display": "Hospital Inpatient Care"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "facility-fee",
                          "display": "Facility Fee"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "inpatient_hospital",
                          "display": "Inpatient hospital"
                        }
                      ],
                      "text": "Inpatient hospital"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              },
                              {
                                "url": "note",
                                "valueString": "Unlimited days per admission"
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "hospital-outpatient",
                      "display": "Hospital Outpatient Care"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "facility-fee",
                          "display": "Facility Fee"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "outpatient_surgery_facility",
                          "display": "Outpatient surgery facility"
                        }
                      ],
                      "text": "Ambulatory surgical center"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "primary-care-visit",
                      "display": "Primary Care Visit"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "primary-care-visit",
                          "display": "Primary Care Visit"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "primary_care",
                          "display": "Primary care visit"
                        }
                      ],
                      "text": "Primary care visit"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "specialist-visit",
                      "display": "Specialist Visit"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "specialist-visit",
                          "display": "Specialist Visit"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "specialist",
                          "display": "Specialist visit"
                        }
                      ],
                      "text": "Specialist visit"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "preventive-care",
                      "display": "Preventive Care/Screening/Immunization"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "preventive-care",
                          "display": "Preventive Care/Screening/Immunization"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "preventive_care",
                          "display": "Preventive care"
                        }
                      ],
                      "text": "Preventive care"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "emergency-room-care",
                      "display": "Emergency Room Care"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "emergency-room-care",
                          "display": "Emergency Room Care"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "emergency_room",
                          "display": "Emergency room"
                        }
                      ],
                      "text": "Emergency care"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_visit"
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              },
                              {
                                "url": "note",
                                "valueString": "The emergency room copay will be waived if you are immediately admitted to the hospital."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 90,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "extension": [
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "OUT"
                              },
                              {
                                "url": "note",
                                "valueString": "Covered worldwide at Original Medicare reimbursable rates (page 4). The document does not print a separate out-of-network amount."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "text": "Covered; amount not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "urgent-care",
                      "display": "Urgent Care"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "urgent-care",
                          "display": "Urgent Care"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "urgent_care",
                          "display": "Urgent care"
                        }
                      ],
                      "text": "Urgently needed services"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "extension": [
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "OUT"
                              },
                              {
                                "url": "note",
                                "valueString": "Covered worldwide at Original Medicare reimbursable rates (page 4). The document does not print a separate out-of-network amount."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "text": "Covered; amount not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "diagnostic-test",
                      "display": "Diagnostic Test"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "diagnostic-test",
                          "display": "Diagnostic Test"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "diagnostic_lab",
                          "display": "Diagnostic lab"
                        }
                      ],
                      "text": "Lab services"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  },
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "diagnostic-test",
                          "display": "Diagnostic Test"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "diagnostic_test",
                          "display": "Diagnostic test"
                        }
                      ],
                      "text": "Diagnostic tests and procedures"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  },
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "diagnostic-test",
                          "display": "Diagnostic Test"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "imaging_standard",
                          "display": "Standard imaging"
                        }
                      ],
                      "text": "Outpatient X-rays"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "imaging",
                      "display": "Imaging (CT/PET/MRI)"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "imaging",
                          "display": "Imaging (CT/PET/MRI)"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "imaging_advanced",
                          "display": "Advanced imaging"
                        }
                      ],
                      "text": "Diagnostic radiology (MRI, CT)"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "mental-health-inpatient",
                      "display": "Mental/Behavioral Health Inpatient Services"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "mental-health-inpatient",
                          "display": "Mental/Behavioral Health Inpatient Services"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "mental_health_inpatient",
                          "display": "Mental health inpatient"
                        }
                      ],
                      "text": "Inpatient mental health"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_day"
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              },
                              {
                                "url": "unitRangeFrom",
                                "valueInteger": 1
                              },
                              {
                                "url": "unitRangeTo",
                                "valueInteger": 90
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "mental-health-outpatient",
                      "display": "Mental/Behavioral Health Outpatient Services"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "mental-health-outpatient",
                          "display": "Mental/Behavioral Health Outpatient Services"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "mental_health_outpatient",
                          "display": "Mental health outpatient"
                        }
                      ],
                      "text": "Outpatient therapy visit"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  },
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "mental-health-outpatient",
                          "display": "Mental/Behavioral Health Outpatient Services"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "mental_health_outpatient",
                          "display": "Mental health outpatient"
                        }
                      ],
                      "text": "Outpatient therapy visit with a psychiatrist"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "skilled-nursing",
                      "display": "Skilled Nursing Care"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "skilled-nursing",
                          "display": "Skilled Nursing Care"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "skilled_nursing_facility",
                          "display": "Skilled nursing facility"
                        }
                      ],
                      "text": "Skilled nursing facility"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              },
                              {
                                "url": "note",
                                "valueString": "Days 1-100"
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "rehabilitation",
                      "display": "Rehabilitation Services"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "rehabilitation",
                          "display": "Rehabilitation Services"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "physical_therapy",
                          "display": "Physical therapy"
                        }
                      ],
                      "text": "Physical therapy"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "emergency-medical-transport",
                      "display": "Emergency Medical Transportation"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "emergency-medical-transport",
                          "display": "Emergency Medical Transportation"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "ambulance",
                          "display": "Ambulance services"
                        }
                      ],
                      "text": "Ambulance"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_one_way_trip"
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 200,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "generic-drugs",
                      "display": "Generic Drugs"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "generic-drugs",
                          "display": "Generic Drugs"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "preferred_generic_drugs",
                          "display": "Preferred generic drugs"
                        }
                      ],
                      "text": "Tier 1 preferred generic drugs"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network",
                            "valueReference": {
                              "display": "Standard retail pharmacies"
                            }
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "PHARMACY_RETAIL_STANDARD"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_30_day_supply"
                              },
                              {
                                "url": "appliesToDeductible",
                                "valueBoolean": false
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": false
                              },
                              {
                                "url": "deductibleRef",
                                "valueString": "pharmacy"
                              },
                              {
                                "url": "note",
                                "valueString": "Standard retail pharmacy, 30-day supply. The page 8 grid also prices Preferred retail, mail-order, and 100-day supplies (quoted in source_references). Part D drug: page 3 says the maximum out-of-pocket does not include prescription drugs."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "qualifiers": [
                          {
                            "text": "Retail, Standard"
                          }
                        ],
                        "value": {
                          "value": 7,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  },
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "generic-drugs",
                          "display": "Generic Drugs"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "generic_drugs",
                          "display": "Generic drugs"
                        }
                      ],
                      "text": "Tier 2 generic drugs"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network",
                            "valueReference": {
                              "display": "Standard retail pharmacies"
                            }
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "PHARMACY_RETAIL_STANDARD"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_30_day_supply"
                              },
                              {
                                "url": "appliesToDeductible",
                                "valueBoolean": false
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": false
                              },
                              {
                                "url": "deductibleRef",
                                "valueString": "pharmacy"
                              },
                              {
                                "url": "note",
                                "valueString": "Standard retail pharmacy, 30-day supply. The page 8 grid also prices Preferred retail, mail-order, and 100-day supplies (quoted in source_references). Part D drug: page 3 says the maximum out-of-pocket does not include prescription drugs."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "qualifiers": [
                          {
                            "text": "Retail, Standard"
                          }
                        ],
                        "value": {
                          "value": 15,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "preferred-brand-drugs",
                      "display": "Preferred Brand Drugs"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "preferred-brand-drugs",
                          "display": "Preferred Brand Drugs"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "preferred_brand_drugs",
                          "display": "Preferred brand drugs"
                        }
                      ],
                      "text": "Tier 3 preferred brand drugs (other than insulin)"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network",
                            "valueReference": {
                              "display": "Standard retail pharmacies"
                            }
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "PHARMACY_RETAIL_STANDARD"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_30_day_supply"
                              },
                              {
                                "url": "appliesToDeductible",
                                "valueBoolean": true
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": false
                              },
                              {
                                "url": "deductibleRef",
                                "valueString": "pharmacy"
                              },
                              {
                                "url": "note",
                                "valueString": "Standard retail pharmacy, 30-day supply. The page 8 grid also prices Preferred retail, mail-order, and 100-day supplies (quoted in source_references). Part D drug: page 3 says the maximum out-of-pocket does not include prescription drugs."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "qualifiers": [
                          {
                            "text": "Retail, Standard"
                          }
                        ],
                        "value": {
                          "value": 47,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "specialty-drugs",
                      "display": "Specialty Drugs"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "specialty-drugs",
                          "display": "Specialty Drugs"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "specialty_drugs",
                          "display": "Specialty drugs"
                        }
                      ],
                      "text": "Tier 5 specialty drugs"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network",
                            "valueReference": {
                              "display": "Standard retail pharmacies"
                            }
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "PHARMACY_RETAIL_STANDARD"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "basis",
                                "valueString": "per_30_day_supply"
                              },
                              {
                                "url": "appliesToDeductible",
                                "valueBoolean": true
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": false
                              },
                              {
                                "url": "deductibleRef",
                                "valueString": "pharmacy"
                              },
                              {
                                "url": "note",
                                "valueString": "Standard retail pharmacy, 30-day supply. On page 8, Tier 5 is 30% for a 30-day supply at Preferred or Standard retail; 100-day supplies and both mail-order columns show Not available. Part D drug: page 3 says the maximum out-of-pocket does not include prescription drugs."
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copaypct",
                              "display": "Copay Percentage"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "qualifiers": [
                          {
                            "text": "Retail, Standard"
                          }
                        ],
                        "value": {
                          "value": 30,
                          "unit": "%",
                          "system": "http://unitsofmeasure.org",
                          "code": "%"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                      "code": "durable-medical-equipment",
                      "display": "Durable Medical Equipment"
                    }
                  ]
                },
                "benefit": [
                  {
                    "type": {
                      "coding": [
                        {
                          "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
                          "code": "durable-medical-equipment",
                          "display": "Durable Medical Equipment"
                        },
                        {
                          "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits",
                          "code": "durable_medical_equipment",
                          "display": "Durable medical equipment"
                        }
                      ],
                      "text": "Durable medical equipment"
                    },
                    "cost": [
                      {
                        "extension": [
                          {
                            "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
                            "valueBoolean": false
                          },
                          {
                            "extension": [
                              {
                                "url": "tierId",
                                "valueString": "IN"
                              },
                              {
                                "url": "sequence",
                                "valueInteger": 1
                              },
                              {
                                "url": "appliesToMoop",
                                "valueBoolean": true
                              }
                            ],
                            "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share"
                          }
                        ],
                        "type": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                              "code": "copay",
                              "display": "Copay Amount"
                            }
                          ]
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "in-network",
                              "display": "In Network"
                            }
                          ]
                        },
                        "value": {
                          "value": 0,
                          "unit": "USD",
                          "system": "urn:iso:std:iso:4217",
                          "code": "USD"
                        }
                      },
                      {
                        "type": {
                          "text": "Not stated in the BPS document"
                        },
                        "applicability": {
                          "coding": [
                            {
                              "system": "http://terminology.hl7.org/CodeSystem/applicability",
                              "code": "out-of-network",
                              "display": "Out of Network"
                            }
                          ]
                        },
                        "value": {
                          "extension": [
                            {
                              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
                              "valueCode": "unknown"
                            }
                          ]
                        }
                      }
                    ]
                  }
                ]
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:584807d0-7e3b-5c6b-bd97-a1585e7c68bd",
      "resource": {
        "resourceType": "Organization",
        "id": "org-scan-health-plan",
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>SCAN Health Plan</p></div>"
        },
        "name": "SCAN Health Plan"
      }
    }
  ]
}