Generated Narrative: MessageHeader cdd9f845-427b-4a48-a02d-279d80b9e415 Profile: UAPI MessageHeader UAPI MessageHeader Timestamp: 2023-03-03 08:10:13-0500 event: uapi-event-type copay-enrollment-insert: copay-enrollment-insert Destinations - Name Endpoint * RisRx https://www.risrx.com/fhir/v1/enroll sender: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 Sources - Name Endpoint * RisRx-Web https://risrx.com/hcpportal Responses - Identifier Code * 2fa9b704-914f-4a3c-b49f-39e2960ede95 OK focus: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
Generated Narrative: List 6a576317-329d-4fd6-9b37-896cb97436e6 messageContext Mode: Change List Status: Current Items Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 Bundle: identifier = Resource identifier: 6a7dbbed-6c6f-48b0-b32e-0a5d89dc72b2; type = message; timestamp = 2024-04-02 08:10:13-0500 Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500 Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3
Generated Narrative: Task 1d68bd2d-4b8d-4e3d-85fc-2632e48e267d status: Requested intent: plan code: Copay for: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 authoredOn: 2023-01-23 08:10:13-0500 requester: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 input type: enroll-by-id value: Patient input type: brandId value: 520d92fe-360c-4bad-98ab-9af941a43a9b input type: brandId value: 135cc659-da2f-4f7b-afec-5b7334ae5bc0
Generated Narrative: Patient 3fd08ef2-34a2-4191-ad04-44353c2f133a Profile: UAPI Patient Ryan Tom Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c (use: usual, )) Contact Detail ph: 1231231234(Home) ph: 1234561234(Mobile) bobster83@example.com 1234 Main St San Francisco CA 94105 US Language: English (preferred) Links: Managing Organization: urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468
Generated Narrative: Organization 01c31a2f-321d-4c6e-8349-206af8a88088 Profile: UAPI Organization identifier: http://vendor.com/ab/HOSP-12345 (use: usual, ) type: Healthcare Provider name: Mid Atlantic Retina 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)
Generated Narrative: Practitioner 695d0991-5e03-46df-934a-85a28acd95c1 Profile: UAPI Practitioner identifier: Provider number/1922071448 (use: official, ), Tax ID number/00000000 (use: official, ), National provider identifier/1639285034 (use: official, ) name: MARISSA CRUZ (Official)
Centers for Medicare & Medicaid Services
Generated Narrative: RelatedPerson 4db51d32-65c3-4f8c-959e-0155c6d14545 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: 1234567890(Mobile) birthDate: 1972-10-29
Generated Narrative: QuestionnaireResponse d5e01ac4-7210-4e10-b288-45adb6b93e66 LinkID Text Definition Answer d5e01ac4-7210-4e10-b288-45adb6b93e66 Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/4321 #xD; consent-to-enroll Do you consent to enroll in the XOLAIR Co-pay Program for drug and administration assistance? Yes #xD; 18-years-or-older Are you 18 years of age or older? Yes #xD; fda-approved-indications Are you using XOLAIR for one of the following FDA-approved indications? [not stated] combination: Moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids. A skin or blood test is performed to see if you have allergies to year-round allergens. It is not known if Xolair is safe and effective in people with asthma under 6 years of age. #xD; commercial-private-insurance Are you 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 Are you using a federal or state-funded insurance program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE. No #xD; residence-state What state do you live in? DC #xD; receiving-medication-from-gpf Are you currently receiving XOLAIR from the Genentech Patient Foundation? No #xD; receiving-assistance-from-charitable-organization Are you currently receiving assistance from any other charitable organization for any of your out-of-pocket costs that are covered by the XOLAIR Co-pay Program? No #xD; agree-to-genentech-privacy-policy I acknowledge and agree that any of my information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to my medical condition, treatments, and health insurance 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. I authorize Genentech to receive, use, and share my personal information in connection with the XOLAIR Co-payProgram. I agree to be contacted by phone, mail, or email about the XOLAIR Co-pay Program. For more information, please see the Genentech Privacy Policy at www.gene.com/privacy- policy. To withdraw from the Program, please contact the Program at (855) 965-2472 Monday through Friday between 9am – 8pm ET. 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. Agree #xD; Documentation for this format
Do you consent to enroll in the XOLAIR Co-pay Program for drug and administration assistance?
Are you using XOLAIR for one of the following FDA-approved indications?
Moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids. A skin or blood test is performed to see if you have allergies to year-round allergens. It is not known if Xolair is safe and effective in people with asthma under 6 years of age.
Are you on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace.
Are you using a federal or state-funded insurance program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.
Are you currently receiving XOLAIR from the Genentech Patient Foundation?
Are you currently receiving assistance from any other charitable organization for any of your out-of-pocket costs that are covered by the XOLAIR Co-pay Program?
I acknowledge and agree that any of my information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to my medical condition, treatments, and health insurance 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. I authorize Genentech to receive, use, and share my personal information in connection with the XOLAIR Co-payProgram. I agree to be contacted by phone, mail, or email about the XOLAIR Co-pay Program. For more information, please see the Genentech Privacy Policy at www.gene.com/privacy- policy. To withdraw from the Program, please contact the Program at (855) 965-2472 Monday through Friday between 9am – 8pm ET.
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.
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: Organization d3637025-883d-4678-9e0a-1d243a338f9f Profile: UAPI Organization identifier: http://vendor.com/ab/PAY-111 (use: usual, ) type: Insurance Company name: Dakotacare 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: Pharmacare telecom: ph: -unknown- Contacts - Telecom * ph: 8778472862(Work)
Generated Narrative: ExplanationOfBenefit 4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d identifier: http://risrx.com/enrollmentId/52f6c814-d858-4f57-a797-a6b065e9d655 (use: usual, ) status: Active type: pharmacy use: Predetermination patient: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 created: 2023-02-07 08:10:13-0500 insurer: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 provider: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 outcome: Complete Insurances - Focal Coverage * true Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
Generated Narrative: Coverage ba8a0351-e1f0-42bf-9590-4ea49b444f56 Profile: UAPI Coverage UAPI Coverage - Card issuance date: 2023-01-01 status: Active type: Pay subscriber: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 subscriberId: EYE00044117 beneficiary: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 period: 2023-01-01 --> 2023-12-31 payor: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 class type: RX BIN value: 600426 name: BIN class type: RX PCN value: 54 name: PCN class type: Group value: EC38517002 name: Group Number class type: Plan value: Xolair-Drug name: Xolair Co Pay program order: 1 network: Genentech
Generated Narrative: ExplanationOfBenefit d9acfd1d-addc-4e0d-b7a6-ff921bde9236 identifier: http://risrx.com/enrollmentId/5195d04d-893e-44bd-b71a-d0ab4a7945b3 (use: usual, ) status: Active type: institutional use: Predetermination patient: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 created: 2023-02-26 21:01:11+0000 insurer: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 provider: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500 outcome: Complete Insurances - Focal Coverage * true urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3
Generated Narrative: Coverage b0574bf9-d016-4af7-a895-269abd739db3 Profile: UAPI Coverage UAPI Coverage - Card issuance date: 2023-02-26 status: Active type: Pay subscriber: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 subscriberId: EYE00044137 beneficiary: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 period: 2023-02-08 --> 2199-12-31 payor: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500 class type: RX BIN value: 600426 name: BIN class type: RX PCN value: 54 name: PCN class type: Group value: EC38532005 name: Group Number class type: Plan value: Xolair-Admin name: Xolair Co Pay program order: 1 network: Genentech
Generated Narrative: Organization d02db104-a75c-433f-8764-9778c2e20626 Profile: UAPI Organization identifier: http://gene.com/ORG-00002 (use: usual, ) type: Insurance Company name: Copay Organization - CRX telecom: ph: 1800654332211(Work)