LinkId	Text	Cardinality	Type	Description & Constraints
Cotellic	Example of questionnaire to be filled out when submitting Copay enrollment bundle for product Cotellic.		Questionnaire	https://fhir.developer.gene.com/Questionnaire/questionnaireCopayCotellic#1.1.19
consent-to-enroll	Does the patient consent to enroll in the Genentech Oncology Co-Pay Program?	1..1	choice	Options: 2 options
18-years-or-older	Is the patient 18 years of age or older	1..1	choice	Options: 2 options
cotellic-fda-approved-indications	Is the patient using COTELLIC® (cobimetinib) for one of the following FDA-approved indications?	1..1	choice	Options: 4 options
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.	1..1	choice	Options: 2 options
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.	1..1	choice	Options: 2 options
have-medicare-card	Does the patient have a Medicare (red, white and blue) card?	1..1	choice	Enable When: federal-state-funded-insurance = Yes Options: 1 option
enter-medicare-number	Enter the Medicare number:	1..1	string	Enable When: have-medicare-card = Yes
residence-state	What state does the patient live in?	1..1	choice
receiving-medication-from-gpf	Is the patient currently receiving Cotellic from the Genentech Patient Foundation?	1..1	choice	Options: 2 options
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 Genentech Oncology Co-pay Program	1..1	choice	Options: 2 options
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 Genentech Genentech Oncology Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Genentech Genentech Oncology 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.	1..1	choice	Options: 2 options
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.	1..1	choice	Options: 2 options
cotellic-receive-copay-for-zelboraf	Does the patient wish to receive co-pay benefits for ZELBORAF as well?	1..1	choice	Enable When: cotellic-fda-approved-indications = melanoma Options: 2 options
cotellic-combo-with-tecentriq	Is the patient also taking TECENTRIQ® (atezolizumab)?	1..1	choice	Enable When: cotellic-receive-copay-for-zelboraf = Yes or No Options: 2 options
cotellic-receive-copay-for-tecentriq	Does the patient wish to receive Copay benefits for Tecentriq as well?	1..1	choice	Enable When: cotellic-combo-with-tecentriq = Yes Options: 2 options
information-correct	All information is correct	1..1	choice	Options: 2 options
assign-debitcard	Do you require a 16-digit virtual card number to process the claim	0..1	choice	Options: 2 options
Documentation for this format

Option Sets

Answer options for consent-to-enroll

• Yes
• No

Answer options for 18-years-or-older

• Yes
• No

Answer options for cotellic-fda-approved-indications

• null#melanoma ("COTELLIC is a prescription medicine that is used with the medicines ZELBORAF® (vemurafenib) and may be used with the medicine TECENTRIQ® (atezolizumab) to treat a type of skin cancer called melanoma that has spread to other parts of the body or cannot be removed by surgery, and that has a certain type of abnormal "BRAF" gene.")
• null#histiocytic-neoplasms ("COTELLIC is a prescription medicine that is used as a single agent for the treatment of adult patients with histiocytic neoplasms. Your healthcare provider will perform a test to make sure that COTELLIC is right for you. It is not known if COTELLIC is safe and effective in children under 18 years of age.")
• null#unsure ("Unsure - Please contact physician's office for information")
• null#none-of-the-above ("None of the above")

Answer options for commercial-private-insurance

• Yes
• No

Answer options for federal-state-funded-insurance

• Yes
• No

Answer options for have-medicare-card

• No

Answer options for receiving-medication-from-gpf

• Yes
• No

Answer options for receiving-assistance-from-charitable-organization

• Yes
• No

Answer options for agree-to-genentech-privacy-policy

• Agree
• Do not Agree

Answer options for agree-to-copay-program-terms

• Agree
• Do not Agree

Answer options for cotellic-receive-copay-for-zelboraf

• Yes
• No

Answer options for cotellic-combo-with-tecentriq

• Yes
• No

Answer options for cotellic-receive-copay-for-tecentriq

• Yes
• No

Answer options for information-correct

• Yes
• No

Answer options for assign-debitcard

• Yes
• No