eg-0229

{
        "@context": "http://health-lifesci.schema.org/",
        "@type": "HealthInsurancePlan",
        "healthPlanId": "12345XX9876543",
        "name": "Sample Gold Health Plan",
        "benefitsSummaryUrl": "http://url/to/summary/benefits/coverage",
        "healthPlanMarketingUrl": "http://url/to/health/plan/information",
        "contactPoint": {
            "@type": "ContactPoint",
            "email": "email@address.com"
        },
        "healthPlanDrugTier": ["http://healthplan.schema.org/PreferredNetwork",
                                  "http://healthplan.schema.org/NonPreferredNetwork"],
        "includesHealthPlanFormulary": [
            {
                "@type": "HealthPlanFormulary",
                "healthPlanDrugTier": "http://healthplan.schema.org/DrugTierGeneric",
                "offersPrescriptionByMail": true,
                "healthPlanCostSharing": [
                    {
                        "@type": "HealthPlanCostSharingSpecification",
                        "healthPlanPharmacyCategory": "1-MONTH-IN-RETAIL",
                        "healthPlanCopay": {
                            "@type": "PriceSpecification",
                            "price": 20,
                            "priceCurrency": "USD"
                        },
                        "healthPlanCopayOption": "http://healthplan.schema.org/HealthPlanCopayAfterDeductable",
                        "healthPlanCoinsuranceRate": 0.1,
                        "healthPlanCoinsuranceOption": "http://healthplan.schema.org/HealthPlanCoinsuranceBeforeDeductable"
                    },
                    {
                       "@type": "HealthPlanCostSharingSpecification",
                        "healthPlanPharmacyCategory": "1-MONTH-IN-MAIL",
                         "healthPlanCopay": {
                            "@type": "PriceSpecification",
                            "price": 0,
                            "priceCurrency": "USD"
                        },
                        "healthPlanCopayOption": "http://healthplan.schema.org/HealthPlanCoPayNoCharge",
                        "healthPlanCoinsuranceRate": 0.2,
                        "healthPlanCoinsuranceOption": "http://healthplan.schema.org/HealthPlanCoinsuranceNone"
                    }
                ]
              }, {
                "@type": "HealthPlanFormulary",
                "healthPlanDrugTier": "http://healthplan.schema.org/DrugTierBrand",
                "offersPrescriptionByMail": true,
                "healthPlanCostSharing": [
                    {
                       "@type": "HealthPlanCostSharingSpecification",
                        "healthPlanPharmacyCategory": "1-MONTH-IN-RETAIL",
                        "healthPlanCopay": {
                            "@type": "PriceSpecification",
                            "price": 15,
                            "priceCurrency": "USD"
                        },
                        "healthPlanCopayOption": "http://healthplan.schema.org/HealthPlanCopayNone",
                        "healthPlanCoinsuranceRate": 0,
                        "healthPlanCoinsuranceOption": "http://healthplan.schema.org/HealthPlanCoinsuranceNone"
                    },
                    {
                       "@type": "HealthPlanCostSharingSpecification",
                        "healthPlanPharmacyCategory": "1-MONTH-IN-MAIL",
                        "healthPlanCopay": {
                            "@type": "PriceSpecification",
                            "price": 20,
                            "priceCurrency": "USD"
                        },
                        "healthPlanCopayOption": "http://healthplan.schema.org/HealthPlanCopayAfterDeductible",
                        "healthPlanCoinsuranceRate": 0.1,
                        "healthPlanCoinsuranceOption": "http://healthplan.schema.org/HealthPlanCoinsuranceBeforeDeductible"
                    }
                ]
            }
        ]
    }

See JSON example.

Background, https://docs.google.com/document/d/1LNew5OEon4uir2D5Zzp0AkUPA7c9nO8reJ_M1pOy-3s/edit#