External - UAPI Response to Copay Search request - example returning 2 matching patients. - Universal API Implementation Guide v1.1.19

Universal API Implementation Guide - Local Development build (v1.1.19). See the Directory of published versions

Example Bundle: External - UAPI Response to Copay Search request - example returning 2 matching patients.

Bundle uapi-copay-search-response-2 of type message

Entry 1 - Full URL = urn:uuid:bbcef4fb-f0ee-4171-8b34-0d8f7b4b8743

Resource MessageHeader:

Generated Narrative: MessageHeader
Resource MessageHeader "bbcef4fb-f0ee-4171-8b34-0d8f7b4b8743"
Texts
- Div
* <div></div>
event: Copay Search Response (Details: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type code copay-search-resp = 'copay-search-resp', stated as 'Copay Search Response')
Sources
- Name Endpoint
* Genentech-FHIR-DEV https://fhir.developer.gene.com/copay-search
Responses
- Identifier Code
* id: 1-63c61a26-4965b3a156f488da6e0800ed OK
focus: See above (urn:uuid:4c2bc01b-7a3e-4856-a698-393e4aeda1cd)

Entry 2 - Full URL = urn:uuid:4c2bc01b-7a3e-4856-a698-393e4aeda1cd

Resource Parameters:

Parameters
responder-page-index 0
responder-page-size 10
search-result urn:uuid:981dc64a-2f66-4f1f-9963-0f991b47ce0b
search-result urn:uuid:392ffecb-41a5-4195-af3a-7c29927041f5

Entry 3 - Full URL = urn:uuid:981dc64a-2f66-4f1f-9963-0f991b47ce0b

Resource Bundle:

Bundle patient1-search-result-patient of type searchset

Entry 1 - Full URL = urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005
Resource Patient:
Timothy Michaelson (OFFICIAL) Male, DoB: 1972-10-29 ( Patient internal identifier: 8132413049(use: USUAL))

Entry 2 - Full URL = urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088
Resource Organization:
Generated Narrative: Organization
Resource Organization "01c31a2f-321d-4c6e-8349-206af8a88088"
Profile: UAPI Organization
Texts
- Div
* <div></div>
identifier: id: HOSP-12345(use: USUAL)
type: Healthcare Provider (OrganizationType#prov)
name: Mid Atlantic Retina
contact
telecom: mar@example.com
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
contact
name: Venus Yardav (OFFICIAL)
telecom: ph: 8882704882(WORK), fax: 8179974042(WORK)

Entry 3 - Full URL = urn:uuid:a7542e8a-760c-4b32-8941-ba3c0752680d
Resource Bundle:
Bundle a7542e8a-760c-4b32-8941-ba3c0752680d of type searchset

Entry 1 - Full URL = urn:uuid:e344813d-eb60-466e-806b-ebd35c988293
Search:mode = match
Resource ExplanationOfBenefit:
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "e344813d-eb60-466e-806b-ebd35c988293"
Texts
- Div
* <div></div>
identifier: id: ad44f19a-42b6-ed11-827c-9e11af077484(use: USUAL)
status: CANCELLED
type: institutional ([not stated]#institutional)
use: PREDETERMINATION
patient: See above (urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005)
created: 2023-04-11 09:01:11+0000
insurer: urn:uuid:d02db104-a75c-433f-8764-9778c2e20626
provider: See above (urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1)
outcome: ERROR
Insurances
- Focal Coverage
* false See above (urn:uuid:e6e8d8c6-a074-4ea5-be1a-a67cb8628a85)

Entry 2 - Full URL = urn:uuid:e6e8d8c6-a074-4ea5-be1a-a67cb8628a85
Search:mode = include
Resource Coverage:
Generated Narrative: Coverage
Resource Coverage "e6e8d8c6-a074-4ea5-be1a-a67cb8628a85"
Profile: UAPI Coverage
Texts
- Div
* <div></div>
status: CANCELLED
type: Pay (ActCode#pay)
subscriber: See above (urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005)
beneficiary: See above (urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005)
Classes
- Type Value Name
* Plan (Coverage Class Codes#plan) id: Vabysmo-Drug Ophthalmology Co Pay program
order: 1
network: Genentech

Entry 3 - Full URL = urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1
Search:mode = include
Resource Practitioner:
Generated Narrative: Practitioner
Resource Practitioner "695d0991-5e03-46df-934a-85a28acd95c1"
Profile: UAPI Practitioner
Texts
- Div
* <div></div>
identifier: Provider identifier: 1922071448(use: OFFICIAL), Tax ID number: 00000000(use: OFFICIAL), National provider identifier: 1639285034(use: OFFICIAL)
name: MARISSA CRUZ (OFFICIAL)

Entry 4 - Full URL = urn:uuid:c712a56a-7cb2-449a-9bd0-edfda29966b6
Resource Bundle:
Bundle c712a56a-7cb2-449a-9bd0-edfda29966b6 of type searchset

Entry 1 - Full URL = urn:uuid:ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a
Search:mode = match
Resource Task:
Generated Narrative: Task
Resource Task "ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"
Texts
- Div
* <div></div>
status: REQUESTED
intent: PLAN
code: Copay (UAPI Code System - Service Request Type#copay)
for: See above (urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005)
authoredOn: 2023-01-23 08:10:13-0500
Inputs
- Type Value[x]
* brandId (uapi-copay-task-input-type#brandId) 9c2693fd-4eb2-4543-a26b-2c85a3450fe2 (uapi-copay-brand-id#9c2693fd-4eb2-4543-a26b-2c85a3450fe2)

Entry 5 - Full URL = urn:uuid:6bccba21-8c51-4d73-8214-8b33a61fd193
Resource Bundle:
Bundle 6bccba21-8c51-4d73-8214-8b33a61fd193 of type searchset

Entry 1 - Full URL = urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a
Search:mode = match
Resource QuestionnaireResponse:
LinkId Text Definition Answer
c29782b4-6ffc-494e-85ab-eee27bfd994a QuestionnaireResponse

consent-to-enroll Does the patient consent to enroll in the Ocrevus Co-Pay Program?

ocrevus-fda-approved-indications Is the patient using OCREVUS for the following FDA-approved indications?

18-years-or-older Is the patient 18 years of age or older

commercial-private-insurance Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace

federal-state-funded-insurance Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.

have-medicare-card Does the patient have a Medicare (red, white and blue) card?

enter-medicare-number Enter the Medicare number:

residence-state What state does the patient live in?

receiving-medication-from-gpf Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?

receiving-assistance-from-charitable-organization Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?

agree-to-genentech-privacy-policy The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and benefits, will be shared with Genentech, the sponsor of the program, its partners, and their respective affiliates. In addition, information shared by the pharmacy/physician, such as the date the prescription was filled, the date the medication was administered by the physician (if applicable) and the amount that will be reimbursed by Genentech will also be shared. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy.

agree-to-copay-program-terms The Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine are not eligible. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the cost associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.

agree-to-admin-copay-program-terms The Administration Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the administration of the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the administration fees associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.

information-correct All information is correct?

Documentation for this format

LinkId	Text	Definition
c29782b4-6ffc-494e-85ab-eee27bfd994a		QuestionnaireResponse
consent-to-enroll	Does the patient consent to enroll in the Ocrevus Co-Pay Program?
ocrevus-fda-approved-indications	Is the patient using OCREVUS for the following FDA-approved indications?
18-years-or-older	Is the patient 18 years of age or older
commercial-private-insurance	Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace
federal-state-funded-insurance	Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.
have-medicare-card	Does the patient have a Medicare (red, white and blue) card?
enter-medicare-number	Enter the Medicare number:
residence-state	What state does the patient live in?
receiving-medication-from-gpf	Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?
receiving-assistance-from-charitable-organization	Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?
agree-to-genentech-privacy-policy	The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and benefits, will be shared with Genentech, the sponsor of the program, its partners, and their respective affiliates. In addition, information shared by the pharmacy/physician, such as the date the prescription was filled, the date the medication was administered by the physician (if applicable) and the amount that will be reimbursed by Genentech will also be shared. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy.
agree-to-copay-program-terms	The Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine are not eligible. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the cost associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.
agree-to-admin-copay-program-terms	The Administration Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the administration of the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the administration fees associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.
information-correct	All information is correct?
Documentation for this format

Entry 4 - Full URL = urn:uuid:392ffecb-41a5-4195-af3a-7c29927041f5

Resource Bundle:

Bundle patient2-search-result-patient of type searchset

Entry 1 - Full URL = urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b
Resource Patient:
Tim Michaelson (OFFICIAL) Male, DoB: 1972-10-29 ( Patient internal identifier: 5122413478(use: USUAL))

Entry 2 - Full URL = urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088
Resource Organization:
Generated Narrative: Organization
Resource Organization "01c31a2f-321d-4c6e-8349-206af8a88088"
Profile: UAPI Organization
Texts
- Div
* <div></div>
identifier: id: HOSP-12345(use: USUAL)
type: Healthcare Provider (OrganizationType#prov)
name: Mid Atlantic Retina
contact
telecom: mar@example.com
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
contact
name: Venus Yardav (OFFICIAL)
telecom: ph: 8882704882(WORK), fax: 8179974042(WORK)

Entry 3 - Full URL = urn:uuid:d2317c7e-82a0-461e-b12e-1418b5e956dc
Resource Bundle:
Bundle d2317c7e-82a0-461e-b12e-1418b5e956dc of type searchset

Entry 1 - Full URL = urn:uuid:4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d
Search:mode = match
Resource ExplanationOfBenefit:
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"
Texts
- Div
* <div></div>
identifier: id: 45d1b98c-587c-ed11-8279-d6b6a2da4722(use: USUAL)
status: ACTIVE
type: pharmacy ([not stated]#pharmacy)
use: PREDETERMINATION
patient: See above (urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b)
created: 2023-02-07 08:10:13-0500
insurer: urn:uuid:d02db104-a75c-433f-8764-9778c2e20626
provider: See above (urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1)
outcome: COMPLETE
Insurances
- Focal Coverage
* true See above (urn:uuid:597540c9-6248-466e-81e0-58e78f15454e)

Entry 2 - Full URL = urn:uuid:597540c9-6248-466e-81e0-58e78f15454e
Search:mode = include
Resource Coverage:
Generated Narrative: Coverage
Resource Coverage "597540c9-6248-466e-81e0-58e78f15454e"
Profile: UAPI Coverage
Texts
- Div
* <div></div>
UAPI Coverage - Card issuance date: 2023-01-01
status: ACTIVE
type: Pay (ActCode#pay)
subscriber: See above (urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b)
subscriberId: id: EYE00044117
beneficiary: See above (urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b)
period: 2023-01-01 --> 2023-12-31
class
type: RX BIN (Coverage Class Codes#rxbin)
value: id: 600426
name: BIN
class
type: RX PCN (Coverage Class Codes#rxpcn)
value: id: 54
name: PCN
class
type: Group (Coverage Class Codes#group)
value: id: EC38517002
name: Group Number
class
type: Plan (Coverage Class Codes#plan)
value: id: Vabysmo-Drug
name: Ophthalmology Co Pay program
order: 1
network: Genentech

Entry 3 - Full URL = urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1
Search:mode = include
Resource Practitioner:
Generated Narrative: Practitioner
Resource Practitioner "695d0991-5e03-46df-934a-85a28acd95c1"
Profile: UAPI Practitioner
Texts
- Div
* <div></div>
identifier: Provider identifier: 1922071448(use: OFFICIAL), Tax ID number: 00000000(use: OFFICIAL), National provider identifier: 1639285034(use: OFFICIAL)
name: MARISSA CRUZ (OFFICIAL)

Entry 4 - Full URL = urn:uuid:144bc1e8-ad84-4447-8bbf-f82a78cc0151
Resource Bundle:
Bundle 144bc1e8-ad84-4447-8bbf-f82a78cc0151 of type searchset

Entry 1 - Full URL = urn:uuid:ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a
Search:mode = match
Resource Task:
Generated Narrative: Task
Resource Task "ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"
Texts
- Div
* <div></div>
status: REQUESTED
intent: PLAN
code: Copay (UAPI Code System - Service Request Type#copay)
for: See above (urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b)
authoredOn: 2023-01-23 08:10:13-0500
Inputs
- Type Value[x]
* brandId (uapi-copay-task-input-type#brandId) 9c2693fd-4eb2-4543-a26b-2c85a3450fe2 (uapi-copay-brand-id#9c2693fd-4eb2-4543-a26b-2c85a3450fe2)

Entry 5 - Full URL = urn:uuid:482ddd0b-93de-4b64-b64d-9fd4f5f77a4a
Resource Bundle:
Bundle 482ddd0b-93de-4b64-b64d-9fd4f5f77a4a of type searchset

Entry 1 - Full URL = urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a
Search:mode = match
Resource QuestionnaireResponse:
LinkId Text Definition Answer
c29782b4-6ffc-494e-85ab-eee27bfd994a QuestionnaireResponse

consent-to-enroll Does the patient consent to enroll in the Ocrevus Co-Pay Program?

ocrevus-fda-approved-indications Is the patient using OCREVUS for the following FDA-approved indications?

18-years-or-older Is the patient 18 years of age or older

commercial-private-insurance Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace

federal-state-funded-insurance Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.

have-medicare-card Does the patient have a Medicare (red, white and blue) card?

enter-medicare-number Enter the Medicare number:

residence-state What state does the patient live in?

receiving-medication-from-gpf Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?

receiving-assistance-from-charitable-organization Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?

agree-to-genentech-privacy-policy The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and benefits, will be shared with Genentech, the sponsor of the program, its partners, and their respective affiliates. In addition, information shared by the pharmacy/physician, such as the date the prescription was filled, the date the medication was administered by the physician (if applicable) and the amount that will be reimbursed by Genentech will also be shared. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy.

agree-to-copay-program-terms The Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine are not eligible. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the cost associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.

agree-to-admin-copay-program-terms The Administration Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the administration of the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the administration fees associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.

information-correct All information is correct?

Documentation for this format