Generated Narrative: MessageHeader 05621068-0e0b-4bc3-a0d0-d21f9270bcfd Profile: UAPI MessageHeader UAPI MessageHeader Timestamp: 2020-03-11 08:10:13-0500 event: uapi-event-type copay-enrollment: copay-enrollment Destinations - Name Endpoint * UAPI-COPAY-ENR-V1.0 https://test-us-e1.apis.roche.com/pharma-cmg-copay-exp-test/v1/enroll sender: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 Sources - Name Endpoint * Vendor_Tailormed http://vendor.com/fhir/enrollmentID/ENR-00001 focus: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500
Generated Narrative: Patient fc2e5a72-c363-4616-ae00-4ad25cbcb45c Profile: UAPI Patient Ryan Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 6bcd8467-0473-4836-9128-2e7972f23177 (use: official, )) Contact Detail ph: 1231231234(Home) ph: 1234561234(Mobile) bobster83@example.com 1234 Main St San Francisco CA 94105 US Language: English (preferred) Links: General Practitioner: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 Managing Organization: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500
Generated Narrative: Organization be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2 Profile: UAPI Organization identifier: http://vendor.com/ab/HOSP-12345 (use: usual, ), National provider identifier/1922071448 (use: usual, ) type: Healthcare Provider name: Cleveland Clinic telecom: ph: 8882704882(Work) address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US Contacts - Name Telecom * MARISSA CRUZ (Official) ph: -unknown-
Generated Narrative: Organization d3637025-883d-4678-9e0a-1d243a338f9f Profile: UAPI Organization identifier: http://vendor.com/ab/PAY-111 (use: usual, ) type: Insurance Company name: Kaiser telecom: ph: 8778472862(Work)
Generated Narrative: Organization 982e97af-668d-41ef-b9f9-2bbc4a059330 Profile: UAPI Organization identifier: http://vendor.com/ab/PAY-145 (use: usual, ) type: Insurance Company name: CVS Specialty telecom: ph: -unknown- Contacts - Telecom * ph: 8778472862(Work)
Generated Narrative: Practitioner cc31cf51-ea4f-4623-bdbb-2ea9e0068a20 Profile: UAPI Practitioner UAPI Practitioner Preferred Contact Method: work-phone UAPI Practitioner Shipment Method: morning identifier: Provider identifier/1922071448 (use: official, ), National provider identifier/1639285034 (use: official, ) name: MARISSA ANNE CRUZ (Official) telecom: ph: 8882704882(Work), fax: 8882704883(Work), prescribercopay@example.com address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US Qualifications - Code * Doctor of Medicine
Generated Narrative: QuestionnaireResponse c29782b4-6ffc-494e-85ab-eee27bfd994a LinkID Text Definition Answer c29782b4-6ffc-494e-85ab-eee27bfd994a Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234 #xD; consent-to-enroll Does the patient consent to enroll in the Ocrevus Co-Pay Program? Yes #xD; ocrevus-fda-approved-indications Is the patient using OCREVUS for the following FDA-approved indications? [not stated] Relapsing-forms-of-multiple-sclerosis-(MS),-to-include-clinically-isolated-syndrome,-relapsing-remitting-disease-and-active-secondary-progressive-disease-or-primary-progressive-forms-of-MS,-in-adults: Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults #xD; 18-years-or-older Is the patient 18 years of age or older, or does the patient have a legal guardian 18 years of age or older to manage the program? Yes #xD; 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 #xD; 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. No #xD; have-medicare-card Does the patient have a Medicare (red, white and blue) card? Yes #xD; enter-medicare-number Enter the Medicare number: M577788 #xD; residence-state What state does the patient live in? CA #xD; receiving-medication-from-gpf Is the patient currently receiving Ocrevus from the Genentech Patient Foundation? No #xD; 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? No #xD; 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 #xD; 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. #xD; 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 #xD; information-correct All information is correct? Yes #xD; Documentation for this format
Does the patient consent to enroll in the Ocrevus Co-Pay Program?
Is the patient using OCREVUS for the following FDA-approved indications?
Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults
Is the patient 18 years of age or older, or does the patient have a legal guardian 18 years of age or older to manage the program?
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
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.
Does the patient have a Medicare (red, white and blue) card?
Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?
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?
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.
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.
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.
Generated Narrative: Coverage 42b41bdb-1781-49aa-a091-78cdd92129df Profile: UAPI Coverage status: Active type: health insurance plan policy subscriber: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 subscriberId: 4353 beneficiary: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 period: 2023-01-01 --> (ongoing) payor: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 class type: RX BIN value: K12345 name: BIN class type: RX PCN value: K234516 name: PCN class type: Group value: KAI2345 name: Group Number class type: Plan value: HMO name: Plan order: 1 network: Kaiser
Generated Narrative: Coverage d212ac11-903c-4040-a3d7-6b3e1874a311 Profile: UAPI Coverage status: Active type: drug policy subscriber: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 subscriberId: 4353 beneficiary: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 period: 2023-01-01 --> (ongoing) payor: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 class type: RX BIN value: K3456 name: BIN class type: RX PCN value: K334455 name: PCN class type: Group value: KAI2345 name: Group Number class type: Plan value: HMO name: Plan order: 1 network: CVS Specialty
Generated Narrative: Task 72d8daf1-f80f-4e56-bfcb-0558caf74feb status: Requested intent: plan code: Copay for: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 authoredOn: 2023-01-23 08:10:13-0500 requester: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 input type: enroll-by-id value: Patient input type: brandId value: 8699576a-3247-429a-9e46-31c00f50f1a0 input type: brandId value: 2e340749-5d09-4615-b0cf-29cb13d30972
Generated Narrative: RelatedPerson 12ed44e8-fde2-415d-9dcc-8e9117c73d2a Profile: UAPI RelatedPerson patient: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 relationship: significant other name: Bob Paul Smith (Official) telecom: ph: 310-462-1234(Mobile) birthDate: 1972-10-29 address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US