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
Example Bundle: External - UAPI Copay Card Enrollment REQUEST 6
Profile: UAPI Bundle - Copay Enrollment
Bundle uapi-copay-bundle-copay-pact-6 of type message
Entry 1 - fullUrl = urn:uuid:d6c3f2ea-5ded-4167-b4a1-5dae67c49c57
Resource MessageHeader:
Profile: UAPI MessageHeader
event: uapi-event-type copay-enrollment: copay-enrollment
Destinations
Name UAPI-ENR-V2.0 Sources
Name Vendor_EZScript
Entry 2 - fullUrl = urn:uuid:f7feff60-0f93-4d09-8d47-ad2da5daad09
Resource List:
messageContext
Mode: Change List Status: Current
Entry 3 - fullUrl = urn:uuid:a5afba98-1ed4-4e91-a69f-856042af8744
Resource Patient:
Profile: UAPI Patient
Kraig Tannebaum (official) Male, DoB: 1989-05-23 ( Patient internal identifier: TMPAT-9029 (use: usual, ))
Contact Detail
- ph: 9283961277(Home)
- kraigt@example.com
- 543 Glass Drive Greensburg PA 15601 US
Language: English (preferred) Links:
- General Practitioner: Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500
- Managing Organization: Bundle: identifier = Resource identifier: 07a9b50e-4753-417f-ae5f-993875af9533; type = message; timestamp = 2025-09-25 06:10:13-0500
Entry 4 - fullUrl = urn:uuid:1c32dbdb-7cef-40b0-b6b3-37b89adaa709
Resource Organization:
Profile: UAPI Organization
identifier:
http://ezscript.com/CC-1111 (use: usual, )type: Healthcare Provider
name: Cleveland Clinic
Contacts
Telecom ph: 8882704882(Work)
Entry 5 - fullUrl = urn:uuid:ee81a811-b11f-4757-ae8a-26a90f54b0f1
Resource Organization:
Profile: UAPI Organization
identifier:
http://ezscript.com/PAY-395 (use: usual, )type: Insurance Company
name: AETNA
Contacts
Telecom ph: 8778472862(Work)
Entry 6 - fullUrl = urn:uuid:de4a57e8-f09c-45c5-a97e-5f5aecebbf10
Resource Organization:
Profile: UAPI Organization
identifier:
http://ezscript.com/PAY-444 (use: usual, )type: Insurance Company
name: CVS
Contacts
Telecom ph: 8778479999(Work)
Entry 7 - fullUrl = urn:uuid:a2e5812b-2243-4ca1-a50a-3eccf3052a0a
Resource Practitioner:
Profile: UAPI Practitioner
identifier: Provider identifier/1922071448 (use: official, ), National provider identifier/1639285034 (use: official, )
name: MARISSA CRUZ (Official)
telecom: ph: 8882704882(Work)
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
Entry 8 - fullUrl = urn:uuid:680f3d4e-6316-4d51-a566-9710ea37e12c
Resource RelatedPerson:
Profile: UAPI RelatedPerson
relationship: spouse
name: Janice Tannebaum (Official)
telecom: ph: 8723961277(Mobile)
address: 543 Glass Drive Greensburg PA 15601 US
Entry 9 - fullUrl = urn:uuid:17e56128-e84e-4732-b228-b3b45346b39f
Resource QuestionnaireResponse:
LinkID Text Definition Answer 17e56128-e84e-4732-b228-b3b45346b39f
Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234 consent-to-enroll
Does the patient consent to enroll in the GAZYVA Immunology Co-Pay Program? Yes Is the patient 18 years of age or older, or does the patient have a legal guardian 18 years of age or older to manage the program?, Yes Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace Yes What state does the patient live in? PA Is the patient currently receiving GAZYVA from the Genentech Patient Foundation? No 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? No 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. Agree 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. Agree 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. Agree Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE. No Would you like to enroll in the patient support program? Yes All information is correct Yes Is the patient using GAZYVA for one of the following FDA-approved indications? [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. Documentation for this format
Entry 10 - fullUrl = urn:uuid:498e4f30-36ee-413e-bb1e-3ae202975bed
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: health insurance plan policy
subscriberId: KT6WSS2PA7
period: 2025-01-01 --> (ongoing)
class
type: Group
value: WAR5103876
name: Group Number
class
type: Plan
value: PPO Preferred Provider Organization
name: Plan
order: 1
network: Aetna
Entry 11 - fullUrl = urn:uuid:e1d7ed46-f68b-450d-a2a4-f8a44028c7b5
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: drug policy
subscriberId: 4353QK230
period: 2025-01-01 --> (ongoing)
class
type: RX BIN
value: K345601
name: BIN
class
type: RX PCN
value: K334455
name: PCN
class
type: Group
value: AET123498
name: Group Number
order: 2
network: CVS
Entry 12 - fullUrl = urn:uuid:5fea0530-ea97-4d44-8bbb-13fc6b4bf46f
Resource Consent:
Profile: UAPI Consent
status: Active
category: Text Consent
provision
Entry 13 - fullUrl = urn:uuid:8e0e1039-9d76-49e3-9e59-f69e34c39c66
Resource Task:
status: Requested
intent: Plan
code: Copay
authoredOn: 2025-09-25 06:10:13-0500
input
type: enroll-by-id
value: Patient
input
type: brandId
value: d0443a4a-edf1-4579-b327-01614f959f08
input
type: brandId
value: 97b5794c-81a0-4243-a08f-a0a07e45a982