<Bundle xmlns="http://hl7.org/fhir">
  <id value="ad8d5826-dd09-4039-b26a-8ecbac749fa9" />
  <meta>
    <lastUpdated value="2019-02-19T10:36:45.195-05:00" />
  </meta>
  <type value="searchset" />
  <total value="173" />
  <link>
    <relation value="self" />
    <url value="https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_format=application%2Fjson%2Bfhir&amp;patient=20140000000001&amp;_count=10&amp;startIndex=0" />
  </link>
  <link>
    <relation value="next" />
    <url value="https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_format=application%2Fjson%2Bfhir&amp;patient=20140000000001&amp;_count=10&amp;startIndex=10" />
  </link>
  <link>
    <relation value="last" />
    <url value="https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_format=application%2Fjson%2Bfhir&amp;patient=20140000000001&amp;_count=10&amp;startIndex=170" />
  </link>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-105966977" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="105966977" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7202381425" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="86253900866" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65862000899" />
              <display value="Metformin Hydrochloride - METFORMIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="180.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1078028414" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1078028414" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9330133972" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="13968571794" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="90" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="51672403203" />
              <display value="Warfarin Sodium - WARFARIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2014-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1084134770" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1084134770" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="699345344" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="37851984863" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781261305" />
              <display value="Amoxicillin - AMOXICILLIN" />
            </coding>
          </service>
          <servicedDate value="2015-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1103807921" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1103807921" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3153367174" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="15549319384" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382002810" />
              <display value="METFORMIN HYDROCHLORIDE - METFORMIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="360.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1173554408" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1173554408" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9809062052" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="55249276131" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="92" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65162010250" />
              <display value="Gabapentin - GABAPENTIN" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1176652336" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1176652336" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9511100068" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="52663574392" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <display value="Catastrophic Coverage Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <code value="C" />
              <display value="Above attachment point" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="9" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="53746046605" />
              <display value="Ibuprofen - IBUPROFEN" />
            </coding>
          </service>
          <servicedDate value="2015-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1262324490" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1262324490" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5586770007" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="90940165609" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <display value="Catastrophic Coverage Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <code value="C" />
              <display value="Above attachment point" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00169643810" />
              <display value="Levemir - INSULIN DETEMIR" />
            </coding>
          </service>
          <servicedDate value="2016-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="3.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1338701780" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1338701780" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4680055731" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="66176799483" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378180901" />
              <display value="Levothyroxine Sodium - LEVOTHYROXINE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1358028474" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1358028474" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3226343972" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="44292016301" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="62175018146" />
            </coding>
          </service>
          <servicedDate value="2014-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1401291937" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1401291937" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6836319401" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="40952800466" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505006501" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2016-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1539481562" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1539481562" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7541393320" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="11136810859" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="02" />
              <display value="Skilled Nursing Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00310075430" />
              <display value="CRESTOR - ROSUVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="450.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="600.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="600.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1627240363" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1627240363" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3433419947" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="94684132931" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="98" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00172208380" />
              <display value="Hydrochlorothiazide - HYDROCHLOROTHIAZIDE" />
            </coding>
          </service>
          <servicedDate value="2016-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1795899026" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1795899026" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5614904466" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="12766718870" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00002879959" />
              <display value="Humalog - INSULIN LISPRO" />
            </coding>
          </service>
          <servicedDate value="2015-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="15.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="450.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="450.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1835211106" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1835211106" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3178470700" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="45661237624" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <display value="Catastrophic Coverage Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <code value="C" />
              <display value="Above attachment point" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="9" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00002879959" />
              <display value="Humalog - INSULIN LISPRO" />
            </coding>
          </service>
          <servicedDate value="2016-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="135.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="4000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="4000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="4000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1877014293" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1877014293" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="961574759" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="9025891176" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="04" />
              <display value="Assisted living facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378180901" />
              <display value="Levothyroxine Sodium - LEVOTHYROXINE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="-10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-1976672146" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="1976672146" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1094115400" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="62937164941" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="55111018015" />
              <display value="Tizanidine - TIZANIDINE HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2016-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2057954637" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2057954637" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2860866921" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="35785534762" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="92" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00078036034" />
              <display value="Diovan - VALSARTAN" />
            </coding>
          </service>
          <servicedDate value="2014-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-20689006816" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="20689006816" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99202" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="76882" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-20803331237" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="20803331237" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="74220" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-20900469405" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="20900469405" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2094316390" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2094316390" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5791771019" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="1702295524" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65862056090" />
              <display value="Pantoprazole Sodium - PANTOPRAZOLE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2105900930" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2105900930" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1021606494" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="19599783243" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051403" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2016-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21160255583" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21160255583" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="83036" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="36415" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21190587966" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21190587966" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92014" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21190587967" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21190587967" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92015" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21262366189" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21262366189" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21262923675" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21262923675" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="76770" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21317670965" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21317670965" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21423661409" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21423661409" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21432496406" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21432496406" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99203" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21540062512" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21540062512" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="52000" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="500.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21574625951" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21574625951" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99203" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21587435294" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21587435294" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="74178" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21587435683" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21587435683" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="88108" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21646686058" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21646686058" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="01214" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="1000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21690812117" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21690812117" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="27130" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="1000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="1000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="4000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="1000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-21876711391" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="21876711391" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99214" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2188771340" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2188771340" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8393241655" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="74024468788" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="04" />
              <display value="Assisted living facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="23155010410" />
              <display value="Metformin hydrochloride - METFORMIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="120.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22037870255" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22037870255" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92014" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92015" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92226" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="4" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92226" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="5" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92250" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="6" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92020" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22037870256" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22037870256" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="76514" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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          <adjudication>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
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              <coding>
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                <display value="Allowed" />
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            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92083" />
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                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
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              <coding>
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                <code value="0" />
                <display value="N/A" />
              </coding>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
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            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
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            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
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        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="1036F" />
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          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
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            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
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          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
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            </category>
            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
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        <item>
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          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="2027F" />
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                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
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                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
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              <code value="3284F" />
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                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
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            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
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              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
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              <coding>
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                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
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          <adjudication>
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                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="6" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8427" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22037870257" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22037870257" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8783" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22181215371" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22181215371" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99214" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22190036153" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22190036153" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="36415" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="84443" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22334530322" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22334530322" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92012" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92015" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="2019F" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="4" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="4177F" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="5" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8427" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="6" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="1036F" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="7" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8442" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="8" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8783" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="C" />
                <display value="Non-covered care" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2234550459" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2234550459" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9223072934" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="84875613304" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="13668010401" />
              <display value="ISOSORBIDE MONONITRATE - ISOSORBIDE MONONITRATE" />
            </coding>
          </service>
          <servicedDate value="2016-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22347822709" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22347822709" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2245892595" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2245892595" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8136724279" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="54974044187" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378395177" />
              <display value="Atorvastatin Calcium - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2015-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2015-08-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2248830908" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2248830908" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2256063964" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="29605821254" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00054429731" />
              <display value="Furosemide - FUROSEMIDE" />
            </coding>
          </service>
          <servicedDate value="2016-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="2.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-22557116835" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="22557116835" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99213" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="70.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="69210" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2259369056" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2259369056" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7135134128" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="70598368938" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="01" />
              <display value="Home" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="31722023990" />
              <display value="Amlodipine Besylate - AMLODIPINE BESYLATE" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2282745150" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2282745150" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9883821155" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="70863141991" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00054429731" />
              <display value="Furosemide - FUROSEMIDE" />
            </coding>
          </service>
          <servicedDate value="2015-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2285081270" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2285081270" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7681964076" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="9386080135" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382031910" />
              <display value="TRAMADOL HYDROCHLORIDE - TRAMADOL HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23030747876" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23030747876" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="98940" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="97112" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="97535" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="4" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="98940" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="5" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="97112" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23030747877" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23030747877" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99202" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="72100" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="98940" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23050915154" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23050915154" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="98940" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="97112" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="98940" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="4" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="97112" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="5" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99212" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23140500507" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23140500507" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92012" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92250" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="80.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2331013546" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2331013546" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2617375130" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="72179651341" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="16252060144" />
              <display value="alendronate sodium - ALENDRONATE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2016-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="12.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-07-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23816923951" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23816923951" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="95819" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23816923952" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23816923952" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="99223" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8427" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="carrier-23861177041" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
          <value value="23861177041" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="44077735787" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
            <code value="71" />
            <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="CARRIER" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="professional" />
            <display value="Professional" />
          </coding>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
            <code value="O" />
            <display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
          </coding>
        </type>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <reference value="Coverage/part-b-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92014" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="2" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="G8428" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="3" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="1036F" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="O" />
                <display value="Other" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="4" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92134" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
        <item>
          <sequence value="5" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
              <code value="92083" />
            </coding>
          </service>
          <quantity>
            <value value="1.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <display value="Carrier Line Reduced Payment Physician Assistant Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
                <code value="0" />
                <display value="N/A" />
              </coding>
            </reason>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
                <display value="Line NCH Medicare Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
                <display value="Line Payment Amount to Beneficiary" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
                <display value="Line Provider Payment Amount" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
                <display value="Line Beneficiary Part B Deductible Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
                <display value="Line Primary Payer (if not Medicare) Paid Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
                <display value="Line Beneficiary Coinsurance Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
                <display value="Line Submitted Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
                <display value="Line Allowed Charge Amount" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <display value="Line Processing Indicator Code" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
                <code value="A" />
                <display value="Allowed" />
              </coding>
            </reason>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2391834363" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2391834363" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9549799603" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="92707840257" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051503" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2413283508" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2413283508" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9176328065" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="54725534075" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="12" />
              <display value="Psychiatric Residential Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65862056090" />
              <display value="Pantoprazole Sodium - PANTOPRAZOLE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2436117680" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2436117680" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="31972383" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="14876204829" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378180301" />
              <display value="Levothyroxine Sodium - LEVOTHYROXINE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-244167885" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="244167885" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1042857850" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="76611941343" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180047903" />
              <display value="SIMVASTATIN - SIMVASTATIN" />
            </coding>
          </service>
          <servicedDate value="2016-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2554788605" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2554788605" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4690195226" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="55980137203" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="10" />
              <display value="Residential Substance Abuse Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="59762154003" />
              <display value="amlodipine besylate - AMLODIPINE BESYLATE" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2589206329" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2589206329" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1353184633" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="60287638083" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="16729000617" />
              <display value="simvastatin - SIMVASTATIN" />
            </coding>
          </service>
          <servicedDate value="2015-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-261155916" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="261155916" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1840121412" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="81620476759" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781572010" />
              <display value="Potassium Chloride - POTASSIUM CHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2657635646" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2657635646" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9407254266" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="78640349712" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="5" />
              <display value="Pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="10" />
              <display value="Residential Substance Abuse Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093742698" />
              <display value="Montelukast Sodium - MONTELUKAST SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2692138046" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2692138046" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="255277609" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="12583995663" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505257908" />
              <display value="ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2016-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2698200169" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2698200169" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6144228743" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="13733619970" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781150610" />
              <display value="Atenolol - ATENOLOL" />
            </coding>
          </service>
          <servicedDate value="2015-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2776277071" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2776277071" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3315489461" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="76528333815" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00186037020" />
              <display value="SYMBICORT - BUDESONIDE; FORMOTEROL FUMARATE" />
            </coding>
          </service>
          <servicedDate value="2014-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="10.2" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2843296995" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2843296995" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1808426716" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="54036891905" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="12" />
              <display value="Psychiatric Residential Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093720298" />
              <display value="Pravastatin Sodium - PRAVASTATIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2943891270" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2943891270" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7587464213" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="85532570298" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="16729018317" />
              <display value="Hydrochlorothiazide - HYDROCHLOROTHIAZIDE" />
            </coding>
          </service>
          <servicedDate value="2016-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-2951467080" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="2951467080" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="634357557" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="86986901512" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="54458088810" />
              <display value="Clopidogrel - CLOPIDOGREL BISULFATE" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="-10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3006158910" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3006158910" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3203050086" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="74079752562" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781261305" />
              <display value="Amoxicillin - AMOXICILLIN" />
            </coding>
          </service>
          <servicedDate value="2015-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3025911284" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3025911284" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5193955198" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="85214216674" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="90" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65862020399" />
              <display value="Losartan Potassium - LOSARTAN POTASSIUM" />
            </coding>
          </service>
          <servicedDate value="2016-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-11-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3037897927" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3037897927" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1460368871" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="44851574835" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="02" />
              <display value="Skilled Nursing Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00406012301" />
              <display value="HYDROCODONE BITARTRATE AND ACETAMINOPHEN - HYDROCODONE BITARTRATE; ACETAMINOPHEN" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-306623187" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="306623187" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7687465939" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="32950669915" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781279010" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2016-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3104866707" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3104866707" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7552663441" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="92135428540" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="62175061743" />
              <display value="Pantoprazole Sodium - PANTOPRAZOLE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2016-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3254764971" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3254764971" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9898935719" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="39671186330" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="62037083110" />
              <display value="Metoprolol Succinate - METOPROLOL SUCCINATE" />
            </coding>
          </service>
          <servicedDate value="2016-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="45.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-05-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3283996090" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3283996090" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7715018181" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="67766737783" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="90" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382013210" />
              <display value="Tamsulosin Hydrochloride - TAMSULOSIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3288888388" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3288888388" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9672321849" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="70474855588" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378395177" />
              <display value="Atorvastatin Calcium - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2015-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="45.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3353329912" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3353329912" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2931674106" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="69978824616" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505017009" />
              <display value="PRAVASTATIN SODIUM - PRAVASTATIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-04-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-338912546" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="338912546" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2782305075" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="66343517912" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="90" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00088221905" />
              <display value="Lantus Solostar - INSULIN GLARGINE" />
            </coding>
          </service>
          <servicedDate value="2014-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="600.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="600.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3484114610" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3484114610" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="629511155" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="78058870266" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505006501" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2014-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="-20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3495220027" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3495220027" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8824996952" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="90115970927" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="15" />
              <display value="Correctional Institution" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505006501" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3579707166" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3579707166" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6080301356" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="12012267910" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051902" />
              <display value="Lisinopril and Hydrochlorothiazide - HYDROCHLOROTHIAZIDE; LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3586838298" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3586838298" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9939619689" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="33613447814" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378022201" />
              <display value="Chlorthalidone - CHLORTHALIDONE" />
            </coding>
          </service>
          <servicedDate value="2016-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="45.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-03-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3596870296" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3596870296" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1948278575" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="63140734035" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="10" />
              <display value="Residential Substance Abuse Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00172208380" />
              <display value="Hydrochlorothiazide - HYDROCHLOROTHIAZIDE" />
            </coding>
          </service>
          <servicedDate value="2015-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2015-11-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3596971176" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3596971176" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1486303164" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="18186660771" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="50458057930" />
              <display value="Xarelto - RIVAROXABAN" />
            </coding>
          </service>
          <servicedDate value="2016-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="22.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3629485012" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3629485012" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3987652969" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="45829643517" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="01" />
              <display value="Home" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051503" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2015-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3653173267" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3653173267" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3695695407" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="56847079311" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505025302" />
              <display value="Clopidogrel - CLOPIDOGREL BISULFATE" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3685927309" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3685927309" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3673621436" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="43557729360" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00310075590" />
              <display value="CRESTOR - ROSUVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3779502196" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3779502196" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7424012487" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="35666420560" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="5" />
              <display value="Pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="12" />
              <display value="Psychiatric Residential Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00173069700" />
              <display value="ADVAIR - SALMETEROL XINAFOATE; FLUTICASONE PROPIONATE" />
            </coding>
          </service>
          <servicedDate value="2014-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3816076384" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3816076384" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3112974504" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="73458836867" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="97" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505257908" />
              <display value="ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="45.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3852191048" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3852191048" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5146017897" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="63049932645" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="55111018015" />
              <display value="Tizanidine - TIZANIDINE HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2015-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3863169674" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3863169674" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1110891398" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="11273891065" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="01" />
              <display value="Home" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="29300012810" />
              <display value="Hydrochlorothiazide - HYDROCHLOROTHIAZIDE" />
            </coding>
          </service>
          <servicedDate value="2016-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="50.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3925457566" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3925457566" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8943777000" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="2388117929" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="29300012510" />
              <display value="meloxicam - MELOXICAM" />
            </coding>
          </service>
          <servicedDate value="2016-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3939434394" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3939434394" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4479762434" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="90320999730" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="98" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00406012301" />
              <display value="HYDROCODONE BITARTRATE AND ACETAMINOPHEN - HYDROCODONE BITARTRATE; ACETAMINOPHEN" />
            </coding>
          </service>
          <servicedDate value="2016-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="120.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3946002440" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3946002440" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="245048194" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="60058331518" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="98" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00597007541" />
              <display value="Spiriva - TIOTROPIUM BROMIDE MONOHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2014-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2015-05-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3985495085" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3985495085" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9835997163" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="18120006015" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093005805" />
              <display value="Tramadol Hydrochloride - TRAMADOL HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-3986227319" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="3986227319" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7303764744" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="80637336513" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00002751001" />
              <display value="Humalog - INSULIN LISPRO" />
            </coding>
          </service>
          <servicedDate value="2016-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="70.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="1000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="2000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="2000.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4035076128" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4035076128" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1067626835" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="98629743838" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00310075590" />
              <display value="CRESTOR - ROSUVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="10.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="60.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4089001643" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4089001643" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="673442749" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="68538176812" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="04" />
              <display value="Assisted living facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505258008" />
              <display value="ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2014-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4122607798" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4122607798" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2041797741" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="19785020044" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="92" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051403" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4158909090" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4158909090" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3211692443" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="69293254739" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="92" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093720298" />
              <display value="Pravastatin Sodium - PRAVASTATIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2014-01-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4168148685" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4168148685" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5582253069" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="29186139502" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180075103" />
              <display value="Amlodipine Besylate - AMLODIPINE BESYLATE" />
            </coding>
          </service>
          <servicedDate value="2014-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2014-05-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4228767941" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4228767941" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6793273295" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="43212459536" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="97" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="50458057930" />
              <display value="Xarelto - RIVAROXABAN" />
            </coding>
          </service>
          <servicedDate value="2016-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="350.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="350.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4230336316" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4230336316" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2122101654" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="49941622582" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <display value="Catastrophic Coverage Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <code value="C" />
              <display value="Above attachment point" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378180310" />
              <display value="Levothyroxine Sodium - LEVOTHYROXINE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2016-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4345767342" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4345767342" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5668265007" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="67692705089" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="91" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="16252060144" />
              <display value="alendronate sodium - ALENDRONATE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="4.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4376190740" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4376190740" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="686655012" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="20428877706" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="93" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="24208046325" />
              <display value="Latanoprost - LATANOPROST" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="7.5" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-01-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4529698447" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4529698447" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8131967051" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="49367222213" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="97" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378001805" />
              <display value="Metoprolol Tartrate - METOPROLOL TARTRATE" />
            </coding>
          </service>
          <servicedDate value="2015-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4589266765" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4589266765" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2253787994" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="80546940575" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="94" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="51991045757" />
              <display value="Polyethylene Glycol 3350 - POLYETHYLENE GLYCOL 3350" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="527.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4673611962" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4673611962" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8384958938" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="81730216454" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051703" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4727741151" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4727741151" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7097342302" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="87431387784" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="01" />
              <display value="Home" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="55111012390" />
              <display value="Atorvastatin Calcium - ATORVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4786294463" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4786294463" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7428061845" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="51264349255" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180012202" />
              <display value="Cephalexin - CEPHALEXIN" />
            </coding>
          </service>
          <servicedDate value="2016-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="20.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4799478927" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4799478927" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1102344404" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="907127513" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="13" />
              <display value="Comprehensive Inpatient Rehabilitation Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093005805" />
              <display value="Tramadol Hydrochloride - TRAMADOL HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4851135083" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4851135083" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6577445807" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="26846920805" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="10" />
              <display value="Residential Substance Abuse Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00186504031" />
              <display value="NEXIUM - ESOMEPRAZOLE MAGNESIUM" />
            </coding>
          </service>
          <servicedDate value="2014-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="700.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="700.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="700.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4890722672" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4890722672" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7136867823" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="75042900618" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00603421232" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4920835609" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4920835609" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6450321119" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="59055172074" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="15" />
              <display value="Correctional Institution" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051403" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="100.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4972041019" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4972041019" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6794928204" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="9485109248" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="97" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="59310057922" />
              <display value="PROAIR - ALBUTEROL SULFATE" />
            </coding>
          </service>
          <servicedDate value="2014-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="8.5" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-4988731665" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="4988731665" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4636455786" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="97616022731" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378180301" />
              <display value="Levothyroxine Sodium - LEVOTHYROXINE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5095198455" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5095198455" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7734642442" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="36649200896" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00603388721" />
              <display value="Hydrocodone Bitartrate And Acetaminophen - HYDROCODONE BITARTRATE; ACETAMINOPHEN" />
            </coding>
          </service>
          <servicedDate value="2015-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2015-10-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5219510661" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5219510661" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="456331540" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="59536554087" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="12" />
              <display value="Psychiatric Residential Treatment Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="50111043301" />
              <display value="Trazodone Hydrochloride - TRAZODONE HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5233324783" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5233324783" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1154856529" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="11795983469" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="13" />
              <display value="Comprehensive Inpatient Rehabilitation Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378001801" />
              <display value="Metoprolol Tartrate - METOPROLOL TARTRATE" />
            </coding>
          </service>
          <servicedDate value="2015-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5365096305" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5365096305" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6836317036" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="44854253505" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505258009" />
              <display value="ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2016-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5422941430" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5422941430" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7214515119" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="16606125895" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093517144" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="4.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5460518163" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5460518163" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6981849185" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="98601472657" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="07" />
              <display value="Inpatient Psychiatric Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051303" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2016-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5479839042" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5479839042" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2273256794" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="51890052693" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="65862056090" />
              <display value="Pantoprazole Sodium - PANTOPRAZOLE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2016-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2016-10-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-54884278" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="54884278" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4163923526" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="17330324425" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="97" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00169633910" />
              <display value="NOVOLOG - INSULIN ASPART" />
            </coding>
          </service>
          <servicedDate value="2015-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="15.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="450.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="450.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5556764698" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5556764698" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6331923020" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="65269476671" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="94" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="59762306001" />
              <display value="azithromycin - AZITHROMYCIN DIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2015-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="6.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2015-09-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5702700036" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5702700036" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3533646550" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="63344417309" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00527132410" />
              <display value="DIGOX - DIGOXIN" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5826056439" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5826056439" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3303066568" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="36136228794" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="95" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093720298" />
              <display value="Pravastatin Sodium - PRAVASTATIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5830027296" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5830027296" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2995417236" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="93307647711" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="08" />
              <display value="Psychiatric Facility – Partial Hospitalization" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="21" />
              <display value="LTC dispensing rule for &lt;=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00310075290" />
              <display value="CRESTOR - ROSUVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2014-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5944329587" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5944329587" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8435493260" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="77391019453" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378395177" />
              <display value="Atorvastatin Calcium - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5974865200" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5974865200" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5354306854" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="29438316556" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="13" />
              <display value="Comprehensive Inpatient Rehabilitation Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00603373932" />
            </coding>
          </service>
          <servicedDate value="2015-05-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-5986510793" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="5986510793" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6854539549" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="14971161594" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382013201" />
              <display value="Tamsulosin Hydrochloride - TAMSULOSIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2016-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-606587255" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="606587255" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="227210056" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="44977762757" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="13" />
              <display value="Comprehensive Inpatient Rehabilitation Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="55111015810" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2015-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6116712725" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6116712725" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8551091831" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="32456553649" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="53746027205" />
              <display value="Sulfamethoxazole and Trimethoprim - SULFAMETHOXAZOLE; TRIMETHOPRIM" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6121244433" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6121244433" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4559578637" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="15002570774" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="04" />
              <display value="Assisted living facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382013210" />
              <display value="Tamsulosin Hydrochloride - TAMSULOSIN HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6343633838" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6343633838" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7802118570" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="76869095479" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="98" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="31722022205" />
              <display value="Gabapentin - GABAPENTIN" />
            </coding>
          </service>
          <servicedDate value="2015-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="120.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6393186080" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6393186080" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4161103905" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="67261284994" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="96" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00781181810" />
              <display value="Furosemide - FUROSEMIDE" />
            </coding>
          </service>
          <servicedDate value="2014-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2014-12-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6459259869" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6459259869" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9277042243" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="92469397463" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="91" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="62175011843" />
              <display value="Omeprazole - OMEPRAZOLE" />
            </coding>
          </service>
          <servicedDate value="2014-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6512957493" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6512957493" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1244572867" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="81679492808" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="23155004710" />
              <display value="Hydrochlorothiazide - HYDROCHLOROTHIAZIDE" />
            </coding>
          </service>
          <servicedDate value="2014-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-664509731" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="664509731" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5012613281" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="69106951062" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <display value="Catastrophic Coverage Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ctstrphc_cvrg_cd" />
              <code value="C" />
              <display value="Above attachment point" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="01" />
              <display value="Home" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="9" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00597007541" />
              <display value="Spiriva - TIOTROPIUM BROMIDE MONOHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2014-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="850.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="900.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="900.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6664372602" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6664372602" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4182556111" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="4829599664" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051703" />
              <display value="Lisinopril - LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2016-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-669574160" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="669574160" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6137250041" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="20763380090" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00603374032" />
            </coding>
          </service>
          <servicedDate value="2015-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="28.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6843835980" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6843835980" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1148112617" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="18599043469" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="04" />
              <display value="Institutional pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="91" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="08" />
              <display value="Process compound for approved ingredients" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378395277" />
              <display value="Atorvastatin Calcium - ATORVASTATIN CALCIUM TRIHYDRATE" />
            </coding>
          </service>
          <servicedDate value="2016-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6848396606" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6848396606" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9025005642" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="93241275145" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00186504031" />
              <display value="NEXIUM - ESOMEPRAZOLE MAGNESIUM" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6923040718" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6923040718" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2339907509" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="19582309117" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00006027731" />
              <display value="JANUVIA - SITAGLIPTIN PHOSPHATE" />
            </coding>
          </service>
          <servicedDate value="2016-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="150.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="400.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="200.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-6945015917" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="6945015917" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="5876298605" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="36340698710" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="96" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="50458057930" />
              <display value="Xarelto - RIVAROXABAN" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="600.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="800.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="800.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7024597110" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7024597110" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6102051486" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="21606047229" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="13" />
              <display value="Comprehensive Inpatient Rehabilitation Facility" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378022201" />
              <display value="Chlorthalidone - CHLORTHALIDONE" />
            </coding>
          </service>
          <servicedDate value="2016-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7058572484" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7058572484" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4263419469" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="75300044601" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="09" />
              <display value="Intermediate care facility for the mentally retarded (ICF/MR)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="63481068447" />
              <display value="Voltaren - DICLOFENAC SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-07-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="100.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-706588035" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="706588035" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3155110815" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="27998765059" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="03" />
              <display value="Home infusion therapy provider" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="91" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="07" />
              <display value="Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505025303" />
              <display value="Clopidogrel - CLOPIDOGREL BISULFATE" />
            </coding>
          </service>
          <servicedDate value="2015-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7066273469" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7066273469" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4043101815" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="32161870474" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="01" />
              <display value="Community/retail pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="03" />
              <display value="Nursing facility (long-term care facility)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="00" />
              <display value="(Unknown value – rarely populated)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093310905" />
              <display value="Amoxicillin - AMOXICILLIN" />
            </coding>
          </service>
          <servicedDate value="2015-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="28.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7101184501" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7101184501" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1381806918" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="49995647394" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="08" />
              <display value="Psychiatric Facility – Partial Hospitalization" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="31722023990" />
              <display value="Amlodipine Besylate - AMLODIPINE BESYLATE" />
            </coding>
          </service>
          <servicedDate value="2016-10-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7155566941" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7155566941" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="1881029448" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="78456208100" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="2" />
              <display value="Telephone" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68382031910" />
              <display value="TRAMADOL HYDROCHLORIDE - TRAMADOL HYDROCHLORIDE" />
            </coding>
          </service>
          <servicedDate value="2014-04-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="10.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7218697568" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7218697568" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3163955530" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="96555686042" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="05" />
              <display value="Custodial Care Facility (residential but not medical care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378023110" />
              <display value="Atenolol - ATENOLOL" />
            </coding>
          </service>
          <servicedDate value="2016-02-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7423408938" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7423408938" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="4811913951" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="12123587733" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="14" />
              <display value="Homeless Shelter" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378001805" />
              <display value="Metoprolol Tartrate - METOPROLOL TARTRATE" />
            </coding>
          </service>
          <servicedDate value="2015-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="60.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7438438613" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7438438613" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="3079759806" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="34663633832" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="51672403201" />
              <display value="Warfarin Sodium - WARFARIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7493432000" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7493432000" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="6601210202" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="77360923764" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="07" />
              <display value="Managed care organization (MCO) pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="06" />
              <display value="Group home (e.g., congregate residential foster care)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="17" />
              <display value="LTC emergency supply remainder (remainder of drug from the emergency supply)" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00406036705" />
            </coding>
          </service>
          <servicedDate value="2014-06-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7504425616" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7504425616" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2516334091" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="26669435867" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="15" />
              <display value="Correctional Institution" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="16252060144" />
              <display value="alendronate sodium - ALENDRONATE SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-12-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="12.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7518202112" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7518202112" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2555722940" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="49138520914" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="05" />
              <display value="Long-term care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="98" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="14" />
              <display value="LTC leave of absence – short fill required for take-home use" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00310075190" />
              <display value="CRESTOR - ROSUVASTATIN CALCIUM" />
            </coding>
          </service>
          <servicedDate value="2014-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="550.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="250.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="550.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="300.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7666711094" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7666711094" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2758798377" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="98690910311" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="92" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00378003210" />
              <display value="Metoprolol Tartrate - METOPROLOL TARTRATE" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="180.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7796651599" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7796651599" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="288516139" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="15222433636" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="00" />
              <display value="Not specified, other patient residence not identified below" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="60505082901" />
              <display value="Fluticasone Propionate - FLUTICASONE PROPIONATE" />
            </coding>
          </service>
          <servicedDate value="2014-11-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="16.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="20.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7833060831" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7833060831" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="2434864758" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="1285382314" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="1" />
              <display value="Written" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="88" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00406036505" />
            </coding>
          </service>
          <servicedDate value="2014-09-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="20.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7837840793" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7837840793" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="9292391156" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="3906328373" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="2" />
              <display value="Substitution Allowed - Patient Requested That Brand Product Be Dispensed" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="B" />
              <display value="Brand" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="99" />
              <display value="Other" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="94" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="19" />
              <display value="Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A)." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00071101468" />
              <display value="Lyrica - PREGABALIN" />
            </coding>
          </service>
          <servicedDate value="2014-03-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="30.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="90.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="100.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-7853023167" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="7853023167" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="8698545126" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="57473123240" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="4" />
              <display value="Facsimile" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="02" />
              <display value="Compounding pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="08" />
              <display value="Psychiatric Facility – Partial Hospitalization" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="05" />
              <display value="Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="68180051902" />
              <display value="Lisinopril and Hydrochlorothiazide - HYDROCHLOROTHIAZIDE; LISINOPRIL" />
            </coding>
          </service>
          <servicedDate value="2014-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-792330336" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="792330336" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="805798453" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="43603402210" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="P" />
              <display value="Partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="08" />
              <display value="Specialty care pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="08" />
              <display value="Psychiatric Facility – Partial Hospitalization" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="18" />
              <display value="LTC patient admit/readmission indicator. This status required new dispensing of medication." />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="62037083101" />
              <display value="Metoprolol Succinate - METOPROLOL SUCCINATE" />
            </coding>
          </service>
          <servicedDate value="2014-08-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="10.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="30.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="50.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
        <payment>
          <date value="2014-08-01" />
        </payment>
      </ExplanationOfBenefit>
    </resource>
  </entry>
  <entry>
    <resource>
      <ExplanationOfBenefit>
        <id value="pde-815303475" />
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/pde_id" />
          <value value="815303475" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
          <value value="7373737957" />
        </identifier>
        <identifier>
          <system value="https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num" />
          <value value="46182654913" />
        </identifier>
        <status value="active" />
        <type>
          <coding>
            <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
            <code value="PDE" />
          </coding>
          <coding>
            <system value="http://hl7.org/fhir/ex-claimtype" />
            <code value="pharmacy" />
            <display value="Pharmacy" />
          </coding>
        </type>
        <organization>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </organization>
        <facility>
          <extension url="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd">
            <valueCoding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </valueCoding>
          </extension>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi" />
            <value value="999999999999999" />
          </identifier>
        </facility>
        <information>
          <sequence value="1" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <display value="Dispense as Written (DAW) Product Selection Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd" />
              <code value="0" />
              <display value="No Product Selection Indicated (may also have missing values)" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="2" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <display value="Dispensing Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd" />
              <code value="C" />
              <display value="Completion of partial fill" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="3" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <display value="Drug Coverage Status Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
              <code value="C" />
              <display value="Covered" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="4" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <display value="Prescription Origination Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/rx_orgn_cd" />
              <code value="3" />
              <display value="Electronic" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="5" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <display value="Brand-Generic Code Reported by Submitting Plan" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd" />
              <code value="G" />
              <display value="Generic Null/missing" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="6" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <display value="Pharmacy service type code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd" />
              <code value="06" />
              <display value="Mail order pharmacy" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="7" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <display value="Patient Residence Code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd" />
              <code value="11" />
              <display value="Hospice" />
            </coding>
          </code>
        </information>
        <information>
          <sequence value="8" />
          <category>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/codesystem/information" />
              <code value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <display value="Submission clarification code" />
            </coding>
          </category>
          <code>
            <coding>
              <system value="https://bluebutton.cms.gov/resources/variables/submsn_clr_cd" />
              <code value="16" />
              <display value="LTC emergency box (e box) /automated dispensing machine" />
            </coding>
          </code>
        </information>
        <careTeam>
          <sequence value="2" />
          <provider>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi" />
              <value value="999999999999999" />
            </identifier>
          </provider>
          <role>
            <coding>
              <system value="http://hl7.org/fhir/claimcareteamrole" />
              <code value="primary" />
              <display value="Primary provider" />
            </coding>
          </role>
        </careTeam>
        <insurance>
          <coverage>
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_cntrct_rec_id" />
            <extension url="https://bluebutton.cms.gov/resources/variables/plan_pbp_rec_num" />
            <reference value="Coverage/part-d-20140000000001" />
          </coverage>
        </insurance>
        <item>
          <sequence value="1" />
          <careTeamLinkId value="2" />
          <service>
            <coding>
              <system value="http://hl7.org/fhir/sid/ndc" />
              <code value="00093720298" />
              <display value="Pravastatin Sodium - PRAVASTATIN SODIUM" />
            </coding>
          </service>
          <servicedDate value="2015-01-01" />
          <quantity>
            <extension url="https://bluebutton.cms.gov/resources/variables/fill_num" />
            <extension url="https://bluebutton.cms.gov/resources/variables/days_suply_num" />
            <value value="90.0" />
          </quantity>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt" />
                <display value="Amount paid by Part D plan for the PDE (drug is covered by Part D)" />
              </coding>
            </category>
            <reason>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd" />
                <code value="C" />
                <display value="Covered" />
              </coding>
            </reason>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt" />
                <display value="Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt" />
                <display value="Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt" />
                <display value="Amount Paid by Patient" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/othr_troop_amt" />
                <display value="Other True Out-of-Pocket (TrOOP) Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/lics_amt" />
                <display value="Amount paid for the PDE by Part D low income subsidy" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/plro_amt" />
                <display value="Reduction in patient liability due to payments by other payers (PLRO)" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt" />
                <display value="Total drug cost (Part D)" />
              </coding>
            </category>
            <amount>
              <value value="40.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
                <code value="https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num" />
                <display value="Gap Discount Amount" />
              </coding>
            </category>
            <amount>
              <value value="0.0" />
              <system value="urn:iso:std:iso:4217" />
              <code value="USD" />
            </amount>
          </adjudication>
        </item>
      </ExplanationOfBenefit>
    </resource>
  </entry>
</Bundle>