Universal API Implementation Guide
1.1.19 - ci-build

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

Questionnaire: External - Cotellic Questionnaire

Official URL: https://fhir.developer.gene.com/Questionnaire/questionnaireCotellic Version: 1.1.19
Active as of 2024-02-19 Computable Name: Cotellic

Example of questionnaire to be filled out when submitting enrollment bundle for product Cotellic.

LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. CotellicExample of questionnaire to be filled out when submitting enrollment bundle for product Cotellic.Questionnairehttps://fhir.developer.gene.com/Questionnaire/questionnaireCotellic#1.1.19
... applied-for-bipaBIPA Service Request Applied?0..1boolean
... applied-for-starterStarter Service Request Applied?0..1boolean
... applied-for-copayCopay Service Request Applied?0..1boolean
... applied-for-appealsAppeals Service Request Applied?0..1boolean
... applied-for-pfPatient Foundation Service Request Applied?0..1boolean
... cotellic-unresectablemetastatic-melanomaDoes the patient have unresectable/metastatic melanoma? 1..1choiceEnable When: applied-for-copay = true
... contact-patientDo not contact patient1..1boolean
... cotellic-cotellic-in-combination-with-zelboraf-vemurafenibIs Cotellic going to be used in combination with ZELBORAF® (vemurafenib)? 1..1choiceEnable When: applied-for-copay = true
... prescription-planIs this a Prescription plan?1..1boolean
... treatment-startedHas treatment started?1..1booleanEnable When: applied-for-copay = true
... prior-authIs prior authorization in place?1..1booleanEnable When: applied-for-bipa = true
... authAuthorization #1..1booleanEnable When: prior-auth = true
... cotellic-drug-allergiesDrug Allergies?1..1stringEnable When: applied-for-pf = true
... cotellic-other-drug-allergiesOther Drug Allergies?1..1stringEnable When: cotellic-drug-allergies = Other
... cotellic-other-prescriptionOther Medicines Prescribed1..1stringEnable When: applied-for-pf = true
... shipment-optionsShipment Options1..1stringEnable When: applied-for-pf = true
... ship-toShip To1..1stringEnable When:
... cotellic-positive-braf-v600eHas the patient been confirmed positive for BRAF V600E?1..1choiceEnable When: applied-for-copay = true
... cotellic-positive-braf-v600kHas the patient been confirmed positive for BRAF V600K?1..1choiceEnable When: applied-for-copay = true
... re-verify-benefitsRe-verify benefits at PA expiration1..1choiceEnable When: applied-for-bipa = true
... specialty-pharmacySpecialty Pharmacy?1..1choiceEnable When: applied-for-bipa = true
... preferred-spPreferred Specialty Pharmacy (Optional)0..1stringEnable When: specialty-pharmacy = true
... onsite-pharmacyOnsite Pharmacy? 1..1choiceEnable When: applied-for-bipa = true
... onsite-pharmacy-nameOnsite Pharmacy Name (Optional)0..1stringEnable When: onsite-pharmacy = true
... line-of-therapyLine of therapy?1..1choiceEnable When: applied-for-copay = true
... line-of-therapy-otherLine of therapy-other?0..1stringEnable When: line-of-therapy = other

doco Documentation for this format