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
In order to determine if a patient qualifies for Copay assistance, patients must answer a set of eligibility questions. In addition, there are non-elgibility questions that may be asked. A question is represened by a ‘Questionnnaire’ and the response is known as a ‘QuestionnaireResponse’. In the Enrollment Request bundle, the client system will provide a QuestionnaireResponse to each question.
Client system is responsible for selecting specific questionnaires which need to be included in the Enrollment bundle. Questionnaires can be retrieved by requesting Questionnaire definitions from the Genentech FHIR Server. Based on product and version number, Genentech will respond back with questionnaires that are specific for that product. details.
The Questionnaire endpoint should be queried with specific product and version.
GET {UAPI_Copay_URL}/v1/questionnaire?name=CoPay%20Cotellic
Example of Questionnaire for Cotellic (updated sample pending as of 7/26/23)
The following questionnaires are common to all products and are required to complete the Copay enrollment of a patient.
| LinkId | Text | Expected Values |
|---|---|---|
| consent-to-enroll | “Does the patient consent to enroll in the [product name] Co-Pay Program?” | Yes or No |
| 18-years-or-older | “Is the patient 18 years of age or older”? | Yes or No |
| (product)-fda-approved-indications | Is the patient using [product name] for one of the following FDA-approved indications? | refer to section 2.4.1 for details |
| 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”. | Yes or No |
| 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.” | Yes or No |
| have-medicare-card | Does the patient have a Medicare (red, white and blue) card? | Yes or No |
| enter-medicare-number | Enter the Medicare Number | Conditional, only add if QuestionnaireResponse to ‘have-medicare-card is ‘Yes’ |
| residence-state | What state does the patient live in? | 2 character state abbreviation |
| receiving-medication-from-gpf | Is the patient currently receiving [product name] from the Genentech Patient Foundation? | Yes or No |
| 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 [product name] Co-pay Program? | Yes or No |
| 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 [product name] Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Genentech [product name] 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 or Do Not Agree |
| 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 or Do Not Agree |
| 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. | Agree or Do Not Agree |
| information-correct | All information is correct | Yes or No |
Example: Cotellic questionnaire for consent eligibility question:
{
"linkId": "consent-to-enroll",
"text": "Does the patient consent to enroll in the Cotellic Co-Pay Program?",
"type": "choice",
"required": true,
"answerOption": [
{
"valueString": "Yes"
},
{
"valueString": "No"
}
]
},
Some questions are applicable only when a specific product is selected. To identify these questions, custom “metadata” questions are introduced in each Questionnaire definition.
Example: Cotellic questionnaire for FDA indication:
{
"linkId": "cotellic-fda-approved-indications",
"text": "Is the patient using COTELLIC® (cobimetinib) for one of the following FDA-approved indications?",
"type": "choice",
"required": true,
"answerOption": [
{
"valueCoding": {
"code": "melanoma",
"display": "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."
}
},
{
"valueCoding": {
"code": "histiocytic-neoplasms",
"display": "COTELLIC is a prescription medicine that is used as a single agent for the treatment of adult patients with histiocytic neoplasms.\n\nYour healthcare provider will perform a test to make sure that COTELLIC is right for you.\n\nIt is not known if COTELLIC is safe and effective in children under 18 years of age."
}
},
{
"valueCoding": {
"code": "unsure",
"display": "Unsure - Please contact physician's office for information"
}
},
{
"valueCoding": {
"code": "none-of-the-above",
"display": "None of the above"
}
}
]
},
In some cases, a patient may be able to select a combination of products (combo therapy). Actual combo therapy-related questions which need to be answered have “required” property set to true and its dependency on the response of a previous question is defined using “enabledWhen” property with reference to specific metadata question.
Example: Cotellic questionnaires for combo therapy with Zelboraf and Tecentriq:
This linkId should be included in enrollment request bundle if Cotellic FDA indication is ‘melanoma’; the response to the question below can be either yes or no.
{
"linkId": "cotellic-receive-copay-for-zelboraf",
"text": "Does the patient wish to receive co-pay benefits for ZELBORAF as well?",
"type": "choice",
"enableWhen": [
{
"question": "cotellic-fda-approved-indications ",
"operator": "=",
"answerString": "melanoma"
}
],
"enableBehavior": "all",
"required": true,
"answerOption": [
{
"valueString": "Yes"
},
{
"valueString": "No"
}
]
},
This linkId should be included in enrollment request bundle if response to “linkId”: “cotellic-receive-copay-for-zelboraf” is either yes or no; the response to the question below can be either yes or no.
{
"linkId": "cotellic-combo-with-tecentriq",
"text": "Is the patient also taking TECENTRIQ® (atezolizumab)?",
"type": "choice",
"enableWhen": [
{
"question": "cotellic-receive-copay-for-zelboraf ",
"operator": "=",
"answerString": "Yes"
},
{
"question": " cotellic-receive-copay-for-zelboraf ",
"operator": "=",
"answerString": "No"
}
],
"enableBehavior": "any",
"required": true,
"answerOption": [
{
"valueString": "Yes"
},
{
"valueString": "No"
}
]
},
This linkId should be included in enrollment request bundle if response to “linkId”: “cotellic-combo-with-tecentriq is yes; the response to the question below can be either yes or no.
{
"linkId": "cotellic-receive-copay-for-tecentriq",
"text": "Does the patient wish to receive Copay benefits for Tecentriq as well?",
"type": "choice",
"enableWhen": [
{
"question": "cotellic-combo-with-tecentriq ",
"operator": "=",
"answerString": "Yes"
}
],
"enableBehavior": "all",
"required": true,
"answerOption": [
{
"valueString": "Yes"
},
{
"valueString": "No"
}
]
},
Note: Administration Copay is available only for the following products: Ocrevus, Xolair, Ophthalmology products, Rituxan (for Immunology)
{
"linkId": "agree-to-admin-copay-program-terms",
"text": "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.\n \n 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.\n \n 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.\n \n 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.",
"type": "choice",
"required": false,
"answerOption": [
{
"valueString": "Agree"
},
{
"valueString": "Do Not Agree"
}
Note: A debit card is only available for the following products: Actemra, Rituxan (for Immunology), Xolair, Ophthalmology and Oncology products. Ocrevus patients automatically receive a debit card; therefore, this questionnaire would be excluded from the request bundle.
{
"linkId": "assign-debitcard",
"text": "Do you require a 16-digit virtual card number to process the claim?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueString": "Yes"
},
{
"valueString": "No"
{
"linkId": "phone-consent",
"text": "enrollment consent via phone",
"answer": [
{
"valueString": "Yes"
}
]
},
In the Enrollment Request bundle, the client system will provide a QuestionnaireResponse to each question.
Responding to the Questionnaire examples in above section, the corresponding QuestionnaireResponses will be formatted as follows:
Example: QuestionnaireResponse to Consent
{
"linkId": "consent-to-enroll",
"text": "Does the patient consent to enroll in the [product name] Co-Pay Program?",
"answer": [
{
"valueString": "Yes"
}
]
},
Example: QuestionnaireResponse to Cotellic FDA Indication
"linkId": "cotellic-fda-approved-indications",
"text": "Is the patient using COTELLIC® (cobimetinib) for one of the following FDA-approved indications?",
"answer": [
{
"valueCoding": {
"code": "melanoma",
"display": "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."
}
}
]
},
Example: QuestionnaireResponse to Cotellic combo therapy with Tecentriq and Zelboraf
"linkId": "cotellic-receive-copay-for-zelboraf",
"text": "Does the patient wish to receive co-pay benefits for ZELBORAF as well?",
"answer": [
{
"valueString": "Yes"
}
]
},
{
"linkId": "cotellic-combo-with-tecentriq",
"text": "Is the patient also taking TECENTRIQ® (atezolizumab)?",
"answer": [
{
"valueString": "Yes"
}
]
},
{
"linkId": "cotellic-receive-copay-for-tecentriq",
"text": "Does the patient wish to receive Copay benefits for Tecentriq as well?",
"answer": [
{
"valueString": "Yes"
}
]
},
Example: QuestionnaireResponse to Administration Copay questionnaire
{
"linkId": "agree-to-admin-copay-program-terms",
"text": "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.\n \n 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.\n \n 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.\n \n 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.",
"answer": [
{
"valueString": "Agree"
}
]
},
Example: QuestionnaireResponse to debit card questionnaire
{
"linkId": "assign-debitcard",
"text": "Do you require a 16-digit virtual card number to process the claim?",
"answer": [
{
"valueString": "Yes"
}
]
},