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

Questionnaire: External - Alecensa Questionnaire

Official URL: https://fhir.developer.gene.com/Questionnaire/questionnaireAlecensa Version: 1.1.20
Active as of 2025-06-25 Computable Name: Alecensa

Example of questionnaire to be filled out when submitting enrollment bundle for product Alecensa.

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. AlecensaExample of questionnaire to be filled out when submitting enrollment bundle for product Alecensa.Questionnairehttps://fhir.developer.gene.com/Questionnaire/questionnaireAlecensa#1.1.20
... applied-for-bipaBIPA Service Request Applied?0..1boolean
... applied-for-starterStarter Service Request Applied?0..1boolean
... applied-for-copayCopay Service Request Applied?0..1boolean
... applied-for-appealsAppeals Service Request Applied?0..1boolean
... applied-for-pfPatient Foundation Service Request Applied?0..1boolean
... alecensa-nsclcMetastatic non-small cell lung cancer (NSCLC)?1..1choiceEnable When:
... contact-patientDo not contact patient1..1boolean
... alecensa-confirmed-positive-alkConfirmed positive for anaplastic lymphoma kinase (ALK)?1..1choiceEnable When:
... prescription-planIs this a Prescription plan?1..1boolean
... treatment-startedHas treatment started?1..1booleanEnable When:
... prior-authIs prior authorization in place?1..1booleanEnable When:
... authAuthorization #1..1booleanEnable When: prior-auth =
... alecensa-drug-allergiesDrug Allergies?1..1stringEnable When: applied-for-pf =
... alecensa-other-drug-allergiesOther Drug Allergies?1..1stringEnable When: alecensa-drug-allergies =
... alecensa-other-prescriptionOther Medicines Prescribed1..1stringEnable When: applied-for-pf =
... shipment-optionsShipment Options1..1stringEnable When: applied-for-pf =
... ship-toShip To1..1stringEnable When:
... re-verify-benefitsRe-verify benefits at PA expiration1..1choiceEnable When:
... onsite-pharmacy-nameOnsite Pharmacy Name (Optional)0..1stringEnable When: onsite-pharmacy =
... line-of-therapyLine of therapy?1..1choiceEnable When: applied-for-copay =
... line-of-therapy-otherLine of therapy-other?0..1stringEnable When: line-of-therapy =
... preferred-spPreferred Specialty Pharmacy (Optional)0..1stringEnable When: specialty-pharmacy =
... onsite-pharmacyOnsite Pharmacy?1..1choiceEnable When:
... specialty-pharmacySpecialty Pharmacy?1..1choiceEnable When:

doco Documentation for this format