Universal API Implementation Guide
1.1.20 - ci-build
Universal API Implementation Guide - Local Development build (v1.1.20) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="uapi-copay-bundle-copay-pact-5"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-copay-enrollment-bundle"/>
</meta>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="RI"/>
<display value="Resource identifier"/>
</coding>
</type>
<system value="http://gene.com/pact"/>
<value value="3b59a2b9-43f1-49ae-9eff-f70633fb776b"/>
<assigner>
<display value="Genentech PACT"/>
</assigner>
</identifier>
<type value="message"/>
<timestamp value="2025-09-25T06:10:13-05:00"/>
<entry>
<fullUrl value="urn:uuid:d6c3f2ea-5ded-4167-b4a1-5dae67c49c57"/>
<resource>
<MessageHeader>
<id value="d6c3f2ea-5ded-4167-b4a1-5dae67c49c57"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-messageheader"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_d6c3f2ea-5ded-4167-b4a1-5dae67c49c57"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader d6c3f2ea-5ded-4167-b4a1-5dae67c49c57</b></p><a name="d6c3f2ea-5ded-4167-b4a1-5dae67c49c57"> </a><a name="hcd6c3f2ea-5ded-4167-b4a1-5dae67c49c57"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-messageheader.html">UAPI MessageHeader</a></p></div><p><b>event</b>: uapi-event-type copay-enrollment: copay-enrollment</p><h3>Destinations</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style="display: none">*</td><td>UAPI-ENR-V2.0</td><td><a href="https://test-us-e1.apis.roche.com/pharma-cmg-ehr-fhir-exp-test/v2/enrollment">https://test-us-e1.apis.roche.com/pharma-cmg-ehr-fhir-exp-test/v2/enrollment</a></td></tr></table><p><b>sender</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-1c32dbdb-7cef-40b0-b6b3-37b89adaa709">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><h3>Sources</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style="display: none">*</td><td>Vendor_EZScript</td><td><a href="http://ezscript.com">http://ezscript.com</a></td></tr></table><p><b>focus</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-f7feff60-0f93-4d09-8d47-ad2da5daad09">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p></div>
</text>
<eventCoding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type"/>
<code value="copay-enrollment"/>
</eventCoding>
<destination>
<name value="UAPI-ENR-V2.0"/>
<endpoint
value="https://test-us-e1.apis.roche.com/pharma-cmg-ehr-fhir-exp-test/v2/enrollment"/>
</destination>
<sender>
<reference value="urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
<type value="Organization"/>
</sender>
<source>
<name value="Vendor_EZScript"/>
<endpoint value="http://ezscript.com"/>
</source>
<focus>
<reference value="urn:uuid:f7feff60-0f93-4d09-8d47-ad2da5daad09"/>
<type value="List"/>
</focus>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:f7feff60-0f93-4d09-8d47-ad2da5daad09"/>
<resource>
<List>
<id value="f7feff60-0f93-4d09-8d47-ad2da5daad09"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="List_f7feff60-0f93-4d09-8d47-ad2da5daad09"> </a><p class="res-header-id"><b>Generated Narrative: List f7feff60-0f93-4d09-8d47-ad2da5daad09</b></p><a name="f7feff60-0f93-4d09-8d47-ad2da5daad09"> </a><a name="hcf7feff60-0f93-4d09-8d47-ad2da5daad09"> </a><h2>messageContext</h2><table class="clstu"><tr><td>Mode: Change List </td><td>Status: Current </td></tr><tr><td/></tr></table><table class="grid"><tr style="backgound-color: #eeeeee"><td><b>Items</b></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-1c32dbdb-7cef-40b0-b6b3-37b89adaa709">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-ee81a811-b11f-4757-ae8a-26a90f54b0f1">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-de4a57e8-f09c-45c5-a97e-5f5aecebbf10">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a2e5812b-2243-4ca1-a50a-3eccf3052a0a">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-680f3d4e-6316-4d51-a566-9710ea37e12c">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-17e56128-e84e-4732-b228-b3b45346b39f">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-5fea0530-ea97-4d44-8bbb-13fc6b4bf46f">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-498e4f30-36ee-413e-bb1e-3ae202975bed">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-e1d7ed46-f68b-450d-a2a4-f8a44028c7b5">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-8e0e1039-9d76-49e3-9e59-f69e34c39c66">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></td></tr></table></div>
</text>
<status value="current"/>
<mode value="changes"/>
<title value="messageContext"/>
<entry>
<item>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:ee81a811-b11f-4757-ae8a-26a90f54b0f1"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:de4a57e8-f09c-45c5-a97e-5f5aecebbf10"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:a2e5812b-2243-4ca1-a50a-3eccf3052a0a"/>
<type value="Practitioner"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<type value="RelatedPerson"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:17e56128-e84e-4732-b228-b3b45346b39f"/>
<type value="QuestionnaireResponse"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"/>
<type value="Consent"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:498e4f30-36ee-413e-bb1e-3ae202975bed"/>
<type value="Coverage"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:e1d7ed46-f68b-450d-a2a4-f8a44028c7b5"/>
<type value="Coverage"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:8e0e1039-9d76-49e3-9e59-f69e34c39c66"/>
<type value="Task"/>
</item>
</entry>
</List>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<resource>
<Patient>
<id value="a5afba98-1ed4-4e91-a69f-856042af8744"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-patient"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_a5afba98-1ed4-4e91-a69f-856042af8744"> </a><p class="res-header-id"><b>Generated Narrative: Patient a5afba98-1ed4-4e91-a69f-856042af8744</b></p><a name="a5afba98-1ed4-4e91-a69f-856042af8744"> </a><a name="hca5afba98-1ed4-4e91-a69f-856042af8744"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-patient.html">UAPI Patient</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Kraig Tannebaum (official) Male, DoB: 1989-05-23 ( Patient internal identifier: TMPAT-9029 (use: usual, ))</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3"><ul><li>ph: 9283961277(Home)</li><li><a href="mailto:kraigt@example.com">kraigt@example.com</a></li><li>543 Glass Drive Greensburg PA 15601 US </li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Language spoken">Language:</td><td colspan="3"><span title="Codes:{urn:ietf:bcp:47 en}">English</span> (preferred)</td></tr><tr><td style="background-color: #f3f5da" title="Patient Links">Links:</td><td colspan="3"><ul><li>General Practitioner: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a2e5812b-2243-4ca1-a50a-3eccf3052a0a">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></li><li>Managing Organization: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-1c32dbdb-7cef-40b0-b6b3-37b89adaa709">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></li></ul></td></tr></table></div>
</text>
<identifier>
<use value="usual"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
</type>
<system value="http://ezscript.com"/>
<value value="TMPAT-9029"/>
<assigner>
<display value="EZScript"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Tannebaum"/>
<given value="Kraig"/>
</name>
<telecom>
<system value="phone"/>
<value value="9283961277"/>
<use value="home"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="email"/>
<value value="kraigt@example.com"/>
<use value="home"/>
<rank value="2"/>
</telecom>
<gender value="male"/>
<birthDate value="1989-05-23"/>
<address>
<line value="543 Glass Drive"/>
<city value="Greensburg"/>
<state value="PA"/>
<postalCode value="15601"/>
<country value="US"/>
</address>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en"/>
<display value="English"/>
</coding>
</language>
<preferred value="true"/>
</communication>
<generalPractitioner>
<reference value="urn:uuid:a2e5812b-2243-4ca1-a50a-3eccf3052a0a"/>
</generalPractitioner>
<managingOrganization>
<reference value="urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
</managingOrganization>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
<resource>
<Organization>
<id value="1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_1c32dbdb-7cef-40b0-b6b3-37b89adaa709"> </a><p class="res-header-id"><b>Generated Narrative: Organization 1c32dbdb-7cef-40b0-b6b3-37b89adaa709</b></p><a name="1c32dbdb-7cef-40b0-b6b3-37b89adaa709"> </a><a name="hc1c32dbdb-7cef-40b0-b6b3-37b89adaa709"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-organization.html">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://ezscript.com</code>/CC-1111 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span></p><p><b>name</b>: Cleveland Clinic</p><p><b>telecom</b>: ph: 8882704882(Work)</p></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://ezscript.com"/>
<value value="CC-1111"/>
<assigner>
<display value="EZScript"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Cleveland Clinic"/>
<telecom>
<system value="phone"/>
<value value="8882704882"/>
<use value="work"/>
<rank value="1"/>
</telecom>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:ee81a811-b11f-4757-ae8a-26a90f54b0f1"/>
<resource>
<Organization>
<id value="ee81a811-b11f-4757-ae8a-26a90f54b0f1"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_ee81a811-b11f-4757-ae8a-26a90f54b0f1"> </a><p class="res-header-id"><b>Generated Narrative: Organization ee81a811-b11f-4757-ae8a-26a90f54b0f1</b></p><a name="ee81a811-b11f-4757-ae8a-26a90f54b0f1"> </a><a name="hcee81a811-b11f-4757-ae8a-26a90f54b0f1"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-organization.html">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://ezscript.com</code>/PAY-395 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}">Insurance Company</span></p><p><b>name</b>: AETNA</p><p><b>telecom</b>: ph: 8778472862(Work)</p></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://ezscript.com"/>
<value value="PAY-395"/>
<assigner>
<display value="EZScript"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="ins"/>
</coding>
</type>
<name value="AETNA"/>
<telecom>
<system value="phone"/>
<value value="8778472862"/>
<use value="work"/>
<rank value="1"/>
</telecom>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:de4a57e8-f09c-45c5-a97e-5f5aecebbf10"/>
<resource>
<Organization>
<id value="de4a57e8-f09c-45c5-a97e-5f5aecebbf10"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_de4a57e8-f09c-45c5-a97e-5f5aecebbf10"> </a><p class="res-header-id"><b>Generated Narrative: Organization de4a57e8-f09c-45c5-a97e-5f5aecebbf10</b></p><a name="de4a57e8-f09c-45c5-a97e-5f5aecebbf10"> </a><a name="hcde4a57e8-f09c-45c5-a97e-5f5aecebbf10"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-organization.html">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://ezscript.com</code>/PAY-444 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}">Insurance Company</span></p><p><b>name</b>: CVS</p><p><b>telecom</b>: ph: 8778479999(Work)</p></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://ezscript.com"/>
<value value="PAY-444"/>
<assigner>
<display value="EZScript"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="ins"/>
</coding>
</type>
<name value="CVS"/>
<telecom>
<system value="phone"/>
<value value="8778479999"/>
<use value="work"/>
<rank value="2"/>
</telecom>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:a2e5812b-2243-4ca1-a50a-3eccf3052a0a"/>
<resource>
<Practitioner>
<id value="a2e5812b-2243-4ca1-a50a-3eccf3052a0a"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_a2e5812b-2243-4ca1-a50a-3eccf3052a0a"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner a2e5812b-2243-4ca1-a50a-3eccf3052a0a</b></p><a name="a2e5812b-2243-4ca1-a50a-3eccf3052a0a"> </a><a name="hca2e5812b-2243-4ca1-a50a-3eccf3052a0a"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-practitioner.html">UAPI Practitioner</a></p></div><p><b>identifier</b>: Provider identifier/1922071448 (use: official, ), National provider identifier/1639285034 (use: official, )</p><p><b>name</b>: MARISSA CRUZ (Official)</p><p><b>telecom</b>: ph: 8882704882(Work)</p><p><b>address</b>: 8 Ranoldo Terrace Cherry Hill NJ 08034 US </p></div>
</text>
<identifier>
<use value="official"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PRN"/>
<display value="Provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1922071448"/>
<assigner>
<display value="Cleveland Clinic"/>
</assigner>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1639285034"/>
</identifier>
<name>
<use value="official"/>
<family value="CRUZ"/>
<given value="MARISSA"/>
</name>
<telecom>
<system value="phone"/>
<value value="8882704882"/>
<use value="work"/>
<rank value="1"/>
</telecom>
<address>
<line value="8 Ranoldo Terrace"/>
<city value="Cherry Hill"/>
<state value="NJ"/>
<postalCode value="08034"/>
<country value="US"/>
</address>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<resource>
<RelatedPerson>
<id value="680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-relatedPerson"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="RelatedPerson_680f3d4e-6316-4d51-a566-9710ea37e12c"> </a><p class="res-header-id"><b>Generated Narrative: RelatedPerson 680f3d4e-6316-4d51-a566-9710ea37e12c</b></p><a name="680f3d4e-6316-4d51-a566-9710ea37e12c"> </a><a name="hc680f3d4e-6316-4d51-a566-9710ea37e12c"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-relatedPerson.html">UAPI RelatedPerson</a></p></div><p><b>patient</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-RoleCode sps}">spouse</span></p><p><b>name</b>: Janice Tannebaum (Official)</p><p><b>telecom</b>: ph: 8723961277(Mobile), 9283961999(Mobile)</p><p><b>address</b>: 543 Glass Drive Greensburg PA 15601 US </p></div>
</text>
<patient>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</patient>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="sps"/>
<display value="spouse"/>
</coding>
</relationship>
<name>
<use value="official"/>
<family value="Tannebaum"/>
<given value="Janice"/>
</name>
<telecom>
<system value="phone"/>
<value value="8723961277"/>
<use value="mobile"/>
</telecom>
<telecom>
<system value="sms"/>
<value value="9283961999"/>
<use value="mobile"/>
<rank value="1"/>
</telecom>
<address>
<line value="543 Glass Drive"/>
<city value="Greensburg"/>
<state value="PA"/>
<postalCode value="15601"/>
<country value="US"/>
</address>
</RelatedPerson>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:17e56128-e84e-4732-b228-b3b45346b39f"/>
<resource>
<QuestionnaireResponse>
<id value="17e56128-e84e-4732-b228-b3b45346b39f"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="QuestionnaireResponse_17e56128-e84e-4732-b228-b3b45346b39f"> </a><p class="res-header-id"><b>Generated Narrative: QuestionnaireResponse 17e56128-e84e-4732-b228-b3b45346b39f</b></p><a name="17e56128-e84e-4732-b228-b3b45346b39f"> </a><a name="hc17e56128-e84e-4732-b228-b3b45346b39f"> </a><table border="1" cellpadding="0" cellspacing="0" style="border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;"><tr style="border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top"><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4B/formats.html#table" title="The linkID for the item">LinkID</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4B/formats.html#table" title="Text for the item">Text</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4B/formats.html#table" title="Minimum and Maximum # of times the item can appear in the instance">Definition</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4B/formats.html#table" title="The type of the item">Answer</a><span style="float: right"><a href="https://hl7.org/fhir/R4B/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_q_root.gif" alt="." style="background-color: white; background-color: inherit" title="QuestionnaireResponseRoot" class="hierarchy"/> 17e56128-e84e-4732-b228-b3b45346b39f</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> consent-to-enroll</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Does the patient consent to enroll in the GAZYVA Immunology Co-Pay Program?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Yes</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> 18-years-or-older</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">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?,</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Yes</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> commercial-private-insurance</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">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</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Yes</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> residence-state</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">What state does the patient live in?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">PA</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> receiving-medication-from-gpf</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is the patient currently receiving GAZYVA from the Genentech Patient Foundation?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">No</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> receiving-assistance-from-charitable-organization</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the GAZYVA Immunology Co-pay Program?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">No</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> agree-to-genentech-privacy-policy</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">The patient acknowledges and agrees that any patient information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to the patient's 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. The patient authorizes Genentech to receive, use, and share the patient's personal information in connection with the GAZYVA Immunology Co-pay Program. The patient agrees to be contacted by phone, mail, or email about the GAZYVA Immunology 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 (844) 492-6729 Monday through Friday between 9am – 8pm ET.</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Agree</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> agree-to-copay-program-terms</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">The Co-pay Program (“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. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. 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 be required to 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 available on the Program Website). 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 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 other 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 each January 1st. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patient is active in the Program. Once a patient's virtual debit card has expired and they are no longer active in the program, the funds will be removed from the virtual debit card. 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 value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Agree</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> agree-to-admin-copay-program-terms</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">The Administration Co-pay Program (“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. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. 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 be required to 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 available at the Program Website). 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 for 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 other 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 patients who reside or receive treatment in a restricted state (e.g. Massachusetts or Rhode Island). 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). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patients are active in the Program. Once a patient’s virtual debit card has expired and they are no longer active in the program, the funds will be removed from the card. 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 value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Agree</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> federal-state-funded-insurance</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">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.</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">No</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> patient-support-program</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Would you like to enroll in the patient support program?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Yes</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="Item" class="hierarchy"/> information-correct</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">All information is correct</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Yes</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> gazyva-for-immunology-fda-approved-indications</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is the patient using GAZYVA for one of the following FDA-approved indications?</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span><span>[not stated] GAZYVA-is-a-CD20-directed-cytolytic-antibody-indicated-for-the-treatment-of-adult-patients-with-active-lupus-nephritis-(LN)-who-are-receiving-standard-therapy.: GAZYVA is a CD20-directed cytolytic antibody indicated for the treatment of adult patients with active lupus nephritis (LN) who are receiving standard therapy. </span></span></td></tr>
<tr><td colspan="4" class="hierarchy"><br/><a href="https://hl7.org/fhir/R4B/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></div>
</text>
<questionnaire
value="https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234"/>
<status value="completed"/>
<subject>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</subject>
<item>
<linkId value="consent-to-enroll"/>
<text
value="Does the patient consent to enroll in the GAZYVA Immunology Co-Pay Program?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="18-years-or-older"/>
<text
value="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?,"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="commercial-private-insurance"/>
<text
value="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"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="residence-state"/>
<text value="What state does the patient live in?"/>
<answer>
<valueString value="PA"/>
</answer>
</item>
<item>
<linkId value="receiving-medication-from-gpf"/>
<text
value="Is the patient currently receiving GAZYVA from the Genentech Patient Foundation?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="receiving-assistance-from-charitable-organization"/>
<text
value="Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the GAZYVA Immunology Co-pay Program?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="agree-to-genentech-privacy-policy"/>
<text
value="The patient acknowledges and agrees that any patient information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to the patient's 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. The patient authorizes Genentech to receive, use, and share the patient's personal information in connection with the GAZYVA Immunology Co-pay Program. The patient agrees to be contacted by phone, mail, or email about the GAZYVA Immunology 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 (844) 492-6729 Monday through Friday between 9am – 8pm ET."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="agree-to-copay-program-terms"/>
<text
value="The Co-pay Program (“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. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. 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 be required to 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 available on the Program Website). 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 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 other 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 each January 1st. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patient is active in the Program. Once a patient's virtual debit card has expired and they are no longer active in the program, the funds will be removed from the virtual debit card. 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 value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="agree-to-admin-copay-program-terms"/>
<text
value="The Administration Co-pay Program (“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. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. 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 be required to 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 available at the Program Website). 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 for 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 other 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 patients who reside or receive treatment in a restricted state (e.g. Massachusetts or Rhode Island). 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). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patients are active in the Program. Once a patient’s virtual debit card has expired and they are no longer active in the program, the funds will be removed from the card. 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 value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="federal-state-funded-insurance"/>
<text
value="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."/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="patient-support-program"/>
<text
value="Would you like to enroll in the patient support program?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="information-correct"/>
<text value="All information is correct"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="gazyva-for-immunology-fda-approved-indications"/>
<text
value="Is the patient using GAZYVA for one of the following FDA-approved indications?"/>
<answer>
<valueCoding>
<code
value="GAZYVA-is-a-CD20-directed-cytolytic-antibody-indicated-for-the-treatment-of-adult-patients-with-active-lupus-nephritis-(LN)-who-are-receiving-standard-therapy."/>
<display
value="GAZYVA is a CD20-directed cytolytic antibody indicated for the treatment of adult patients with active lupus nephritis (LN) who are receiving standard therapy. "/>
</valueCoding>
</answer>
</item>
</QuestionnaireResponse>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:498e4f30-36ee-413e-bb1e-3ae202975bed"/>
<resource>
<Coverage>
<id value="498e4f30-36ee-413e-bb1e-3ae202975bed"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_498e4f30-36ee-413e-bb1e-3ae202975bed"> </a><p class="res-header-id"><b>Generated Narrative: Coverage 498e4f30-36ee-413e-bb1e-3ae202975bed</b></p><a name="498e4f30-36ee-413e-bb1e-3ae202975bed"> </a><a name="hc498e4f30-36ee-413e-bb1e-3ae202975bed"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-coverage.html">UAPI Coverage</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span></p><p><b>subscriber</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-680f3d4e-6316-4d51-a566-9710ea37e12c">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>subscriberId</b>: KT6WSS2PA7</p><p><b>beneficiary</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>period</b>: 2025-01-01 --> (ongoing)</p><p><b>payor</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-ee81a811-b11f-4757-ae8a-26a90f54b0f1">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}">Group</span></p><p><b>value</b>: WAR5103876</p><p><b>name</b>: Group Number</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}">Plan</span></p><p><b>value</b>: PPO Preferred Provider Organization</p><p><b>name</b>: Plan</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Aetna</p></div>
</text>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="HIP"/>
<display value="health insurance plan policy"/>
</coding>
</type>
<subscriber>
<reference value="urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<type value="RelatedPerson"/>
</subscriber>
<subscriberId value="KT6WSS2PA7"/>
<beneficiary>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2025-01-01"/>
</period>
<payor>
<reference value="urn:uuid:ee81a811-b11f-4757-ae8a-26a90f54b0f1"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="WAR5103876"/>
<name value="Group Number"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="PPO Preferred Provider Organization"/>
<name value="Plan"/>
</class>
<order value="1"/>
<network value="Aetna"/>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:e1d7ed46-f68b-450d-a2a4-f8a44028c7b5"/>
<resource>
<Coverage>
<id value="e1d7ed46-f68b-450d-a2a4-f8a44028c7b5"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_e1d7ed46-f68b-450d-a2a4-f8a44028c7b5"> </a><p class="res-header-id"><b>Generated Narrative: Coverage e1d7ed46-f68b-450d-a2a4-f8a44028c7b5</b></p><a name="e1d7ed46-f68b-450d-a2a4-f8a44028c7b5"> </a><a name="hce1d7ed46-f68b-450d-a2a4-f8a44028c7b5"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-coverage.html">UAPI Coverage</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode DRUGPOL}">drug policy</span></p><p><b>subscriber</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-680f3d4e-6316-4d51-a566-9710ea37e12c">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>subscriberId</b>: 4353QK230</p><p><b>beneficiary</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>period</b>: 2025-01-01 --> (ongoing)</p><p><b>payor</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-de4a57e8-f09c-45c5-a97e-5f5aecebbf10">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxbin}">RX BIN</span></p><p><b>value</b>: K345601</p><p><b>name</b>: BIN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}">RX PCN</span></p><p><b>value</b>: K334455</p><p><b>name</b>: PCN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}">Group</span></p><p><b>value</b>: AET123498</p><p><b>name</b>: Group Number</p></blockquote><p><b>order</b>: 2</p><p><b>network</b>: CVS</p></div>
</text>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="DRUGPOL"/>
<display value="drug policy"/>
</coding>
</type>
<subscriber>
<reference value="urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<type value="RelatedPerson"/>
</subscriber>
<subscriberId value="4353QK230"/>
<beneficiary>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2025-01-01"/>
</period>
<payor>
<reference value="urn:uuid:de4a57e8-f09c-45c5-a97e-5f5aecebbf10"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxbin"/>
<display value="RX BIN"/>
</coding>
</type>
<value value="K345601"/>
<name value="BIN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxpcn"/>
<display value="RX PCN"/>
</coding>
</type>
<value value="K334455"/>
<name value="PCN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="AET123498"/>
<name value="Group Number"/>
</class>
<order value="2"/>
<network value="CVS"/>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"/>
<resource>
<Consent>
<id value="5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-consent"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Consent_5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"> </a><p class="res-header-id"><b>Generated Narrative: Consent 5fea0530-ea97-4d44-8bbb-13fc6b4bf46f</b></p><a name="5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"> </a><a name="hc5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-consent.html">UAPI Consent</a></p></div><p><b>status</b>: Active</p><p><b>scope</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/consentscope patient-privacy}">Privacy Consent</span></p><p><b>category</b>: <span title="Codes:{http://loinc.org 59284-0}">Text Consent</span></p><p><b>patient</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>dateTime</b>: 2025-09-25 10:01:08+0000</p><p><b>performer</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-680f3d4e-6316-4d51-a566-9710ea37e12c">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>policyRule</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/consentpolicycodes hipaa-auth}">HIPAA Authorization</span></p><h3>Provisions</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Opt In</td></tr></table></div>
</text>
<status value="active"/>
<scope>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/consentscope"/>
<code value="patient-privacy"/>
<display value="Privacy Consent"/>
</coding>
</scope>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="59284-0"/>
<display value="Text Consent"/>
</coding>
</category>
<patient>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</patient>
<dateTime value="2025-09-25T10:01:08Z"/>
<performer>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/exact-contact-point">
<valueString value="telecom[1]"/>
</extension>
<reference value="urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c"/>
<type value="RelatedPerson"/>
</performer>
<policyRule>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/consentpolicycodes"/>
<code value="hipaa-auth"/>
<display value="HIPAA Authorization"/>
</coding>
</policyRule>
<provision>
<type value="permit"/>
</provision>
</Consent>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:8e0e1039-9d76-49e3-9e59-f69e34c39c66"/>
<resource>
<Task>
<id value="5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Task_5fea0530-ea97-4d44-8bbb-13fc6b4bf46f"> </a><p class="res-header-id"><b>Generated Narrative: Task 5fea0530-ea97-4d44-8bbb-13fc6b4bf46f</b></p><p><b>status</b>: Requested</p><p><b>intent</b>: plan</p><p><b>code</b>: <span title="Codes:{https://fhir.developer.gene.com/CodeSystem/uapi-sr-type copay}">Copay</span></p><p><b>for</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-a5afba98-1ed4-4e91-a69f-856042af8744">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><p><b>authoredOn</b>: 2025-09-25 06:10:13-0500</p><p><b>requester</b>: <a href="Bundle-uapi-copay-bundle-copay-pact-4.html#urn-uuid-1c32dbdb-7cef-40b0-b6b3-37b89adaa709">Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500</a></p><blockquote><p><b>input</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type enroll-by-id}">enroll-by-id</span></p><p><b>value</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-enrollby-id 1}">Patient</span></p></blockquote><blockquote><p><b>input</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type brandId}">brandId</span></p><p><b>value</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id d0443a4a-edf1-4579-b327-01614f959f08}">d0443a4a-edf1-4579-b327-01614f959f08</span></p></blockquote><blockquote><p><b>input</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type brandId}">brandId</span></p><p><b>value</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id 97b5794c-81a0-4243-a08f-a0a07e45a982}">97b5794c-81a0-4243-a08f-a0a07e45a982</span></p></blockquote></div>
</text>
<status value="requested"/>
<intent value="plan"/>
<code>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-sr-type"/>
<code value="copay"/>
</coding>
</code>
<for>
<reference value="urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744"/>
<type value="Patient"/>
</for>
<authoredOn value="2025-09-25T06:10:13-05:00"/>
<requester>
<reference value="urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709"/>
<type value="Organization"/>
</requester>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="enroll-by-id"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-enrollby-id"/>
<code value="1"/>
<display value="Patient"/>
</coding>
</valueCodeableConcept>
</input>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="d0443a4a-edf1-4579-b327-01614f959f08"/>
</coding>
</valueCodeableConcept>
</input>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="97b5794c-81a0-4243-a08f-a0a07e45a982"/>
</coding>
</valueCodeableConcept>
</input>
</Task>
</resource>
</entry>
</Bundle>