<Coverage xmlns="http://hl7.org/fhir">
    <id value="Coverage1" />
    <extension url="http://eam.trizetto.com/premiumWithholdOption">
        <valueIdentifier>
            <type>
                <coding>
                    <code value="PWO" />
                    <display value="Premium Withhold Option" />
                </coding>
            </type>
            <value value="S" />
            <period>
                <start value="2021-01-01T00:00:00" />
            </period>
        </valueIdentifier>
    </extension>
    <status value="active" />
    <policyHolder>
        <type value="Patient" />
        <identifier>
            <value value="9C78C01NY05" />
        </identifier>
        <display value="MBI" />
    </policyHolder>
    <subscriber>
        <type value="Patient" />
        <identifier>
            <value value="9C78C01NY05" />
        </identifier>
        <display value="MBI" />
    </subscriber>
    <subscriberId value="IDTRR1" />
    <beneficiary>
        <type value="Patient" />
        <identifier>
            <value value="9C78C01NY05" />
        </identifier>
        <display value="MBI" />
    </beneficiary>
    <dependent value="IDTRR1" />
    <relationship>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/subscriber-relationship" />
            <code value="self" />
            <display value="Self" />
        </coding>
    </relationship>
    <period>
        <start value="2022-09-26T19:59:15.4623478+00:00" />
    </period>
    <payor>
        <reference value="Organization/1" />
    </payor>
    <class>
        <type>
            <coding>
                <system value="http://eam.trizetto.com/CodeSystem/coverage-class" />
                <code value="subgroup" />
                <display value="SubGroup" />
            </coding>
        </type>
        <value value="33000" />
        <name value="SCC" />
    </class>
    <class>
        <type>
            <coding>
                <system value="http://eam.trizetto.com/CodeSystem/coverage-class" />
                <code value="plan" />
                <display value="Plan" />
            </coding>
        </type>
        <value value="H1001" />
        <name value="Plan ID" />
    </class>
    <class>
        <type>
            <coding>
                <system value="http://eam.trizetto.com/CodeSystem/coverage-class" />
                <code value="subplan" />
                <display value="SubPlan" />
            </coding>
        </type>
        <value value="001" />
        <name value="PBP" />
    </class>
    <class>
        <type>
            <coding>
                <system value="http://eam.trizetto.com/CodeSystem/coverage-class" />
                <code value="LISL" />
                <display value="Low Income Subsidy Level" />
            </coding>
        </type>
        <value value="000" />
        <name value="LIS Level" />
    </class>
    <order value="1" />
    <costToBeneficiary>
        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/coverage-copay-type" />
                <code value="copay" />
                <display value="Copay Amount" />
            </coding>
            <text value="LIS Copay Category" />
        </type>
        <valueQuantity>
            <value value="4.00" />
        </valueQuantity>
    </costToBeneficiary>
</Coverage>