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
When submitting a Co-Pay enrollment, our Co-pay administrators have established set values for specific fields that help facilitate the processing of enrollments.
The enroll-by-id field identifies who is applying for Co-pay assistance:
| Expected Value | Who is applying |
|---|---|
| 1 | Patient |
| 2 | Legally Authorized Person on behalf of the patient (LAP) |
| 4 | HCP on behalf of patient |
| 6 | HCP on behalf of LAP |
| 8 | Specialty Pharmacy |
| 10 | Specialty Pharmacy on behalf of LAP |
There are two types of assistance a patient can enroll into. A patient can be enrolled in one or both types of assistance programs.
NOTE: Not all brands offer both types of copay assistance.
| Product | Drug Copay Offered | Admin Copay Offered |
|---|---|---|
| Actemra | Yes | No |
| Alecensa | Yes | No |
| Avastin | Yes | No |
| Cotellic | Yes | No |
| Enspryng | Yes | No |
| Erivedge | Yes | No |
| Esbriet | Yes | No |
| Evrysdi | Yes | No |
| Gazyva | Yes | No |
| Herceptin | Yes | No |
| Herceptin Hylecta | Yes | No |
| Itovebi | Yes | No |
| Kadcyla | Yes | No |
| Lucentis | Yes | Yes |
| Lunsumio | Yes | No |
| Ocrevus | Yes | Yes |
| Ocrevus Zunovo | Yes | Yes |
| Perjeta | Yes | No |
| Phesgo | Yes | No |
| PiaSky | Yes | No |
| Polivy | Yes | No |
| Pulmozyme | Yes | No |
| Rituxan Hycela | Yes | No |
| Rituxan for Immunology | Yes | Yes |
| Rituxan for Oncology | Yes | No |
| Rozlytrek | Yes | No |
| Susvimo | Yes | Yes |
| Tecentriq | Yes | No |
| Tecentriq Hybreza | Yes | No |
| Vabysmo | Yes | Yes |
| Venclexta | Yes | No |
| Xolair | Yes | Yes |
| Zelboraf | Yes | No |
The Brand Id is a required field that identifies the product and the type(s) of assistance the patient is applying for. Multiple Brand Ids can be included in the FHIR bundle when (1) a patient requests to be enrolled in both the drug and admin copay programs and (2) a patient enrolls for a combo therapy.
| Program | Brand | Brand Id (Production) | Brand Id (UAT) |
|---|---|---|---|
| BioOncology | Alecensa | 18a1ea34-8e8c-413e-9043-ccd4c25f1a63 | bfa7fafa-4c9e-444a-861d-2bbc8dd2b656 |
| BioOncology | Avastin | d1cdefa8-6140-409e-b519-872ea1db6b03 | b5a3b04b-74af-481f-99eb-36a532e7c7da |
| BioOncology | Columvi | f695fb8a-cb22-4a85-b76a-7976c134070b | 657e0528-e7b5-4969-b92f-8866487bd94e |
| BioOncology | Cotellic | c127a362-5d2e-4a8e-a552-1c606eaf58f7 | a5b1cc66-973e-42df-93a0-6140b3e47b6e |
| BioOncology | Erivedge | 179ec971-ebef-4d2c-b87f-7a83b29eeeb2 | 88adb957-3ccd-4ff2-8c89-1423462bc02b |
| BioOncology | Gazyva | 9b4e490f-ffbe-4aa7-943f-ea621cb705d9 | 92418abc-9ff2-4c4e-9bcf-dce6b8f6e5e5 |
| BioOncology | Herceptin | a8279013-054a-4cc2-896b-d29adfec5972 | 0ca3a21d-9ffe-4549-a368-90276d8694ae |
| BioOncology | Herceptin Hylecta | a548efb3-267d-49e8-9e0e-41a35508e11d | 23f4df7a-9ac7-45cb-a84e-556afa5212c5 |
| BioOncology | Itovebi | a87d66ee-5f46-4bad-b299-a8551720d799 | b4ab86db-67d2-4e8f-bdbc-23a958c3962f |
| BioOncology | Kadcyla | 1c4a475b-c10e-4974-888e-f996ec35c136 | 2e3f20bb-a26a-4a9f-b9a6-16054180866d |
| BioOncology | Lunsumio | d58545cf-ddc0-4535-8de7-5ea41b9059d3 | 39716479-0982-4d44-9964-9dfd5737416a |
| BioOncology | Perjeta | aa2f6a82-c04c-480d-ab6e-2bc79d806353 | aab2fa4b-d7d8-4668-87f7-25ec9e2c42ba |
| BioOncology | Phesgo | c1893d9a-bc5a-4b91-8885-b4a22a59b97d | d47df534-659c-4647-98ae-b490cc821ba9 |
| BioOncology | Polivy | 2195a20c-4cd6-47d2-8ff6-f458b89281f4 | dff24507-0774-493f-9a8f-6f3e0cdf78b5 |
| BioOncology | Rituxan Hycela | 31209b89-fa46-4541-8d59-88b662c564cb | 4af9d0d0-d9a1-4737-b7b2-839a7f0e31f4 |
| BioOncology | Rituxan for Oncology | e36cda77-1c22-467a-b5fd-18ceddb6b023 | c52cf8ac-e452-40de-9324-de9b70b74375 |
| BioOncology | Rozlytrek | edf443bc-5fca-404c-a7ca-dbee11a564e5 | 439d3453-447b-48c7-84c8-e2055042bc0d |
| BioOncology | Tecentriq | 29c08e19-e811-496f-9521-b10ebf18f197 | 4143da8c-7622-424b-b666-84af907ac69e |
| BioOncology | Tecentriq Hybreza | acc8b209-50d3-45b2-8a84-73466c2e2cf5 | 4f35a11a-da5f-4a19-810e-99f975a5c4b9 |
| BioOncology | Venclexta | 8371a7ff-70c8-411f-9778-6eca47ce28c5 | d814ba03-8fc4-42fa-bb6e-b56132ccf63f |
| BioOncology | Zelboraf | eb8f18ce-a05d-4775-bf5a-1b97f0df8dae | be76c957-d967-443c-b1c4-eedc150e2c5c |
| Enspryng | Enspryng | 249f47a4-4f65-4d89-9308-26b2ac3b3aac | e9d400c1-4154-4c27-ad5e-edeb61c2e15b |
| Esbriet | Esbriet | acb694cf-5d5b-45ed-aab4-6e16cd27a1b5 | 2aa02623-061b-44e2-9212-0e6b54025ac3 |
| Evrysdi | Evrysdi | 80d33880-d5c3-4c04-b5fa-0e6b83becf99 | 6eaf95e3-3dc9-4b70-9441-a309809a217a |
| Hemlibra | Hemlibra | b0c68be7-42ab-476d-9a34-ecb98fee35f6 | e8d84bf8-25a8-11ee-be56-0242ac120002 |
| Ocrevus | Ocrevus Drug | 8699576a-3247-429a-9e46-31c00f50f1a0 | 9c2693fd-4eb2-4543-a26b-2c85a3450fe2 |
| Ocrevus | Ocrevus Admin | 2e340749-5d09-4615-b0cf-29cb13d30972 | b8d8f918-8f39-4bb7-9e0e-ef1f26cc6e55 |
| Ocrevus Zunovo | Ocrevus Zunovo Drug | 8699576a-3247-429a-9e46-31c00f50f1a0 | 9c2693fd-4eb2-4543-a26b-2c85a3450fe2 |
| Ocrevus Zunovo | Ocrevus Zunovo Admin | 2e340749-5d09-4615-b0cf-29cb13d30972 | b8d8f918-8f39-4bb7-9e0e-ef1f26cc6e55 |
| Ophthalmology | Susvimo | ab812753-0273-4214-9822-8174bee8e42d | 1d5a38ac-e536-4b91-8b7c-62dc9f2bd56e |
| Ophthalmology | Lucentis | f0b91ca8-6a86-49d4-acce-ed7ea2df4d58 | 477136f7-ac31-4c07-ad07-2e010cbb2863 |
| Ophthalmology | Vabysmo | 2f34dfb8-81ea-4ea5-9f8d-5cf96c7caa91 | bf2a4e22-6d86-4e6d-b8a9-76f26fae2748 |
| Ophthalmology | Ophthamology Admin | f3681b89-6efd-4362-905f-6304abbfd6b5 | 93d32d3c-3ca8-4eed-ac55-8f4a93f61bdc |
| PiaSky | PiaSky | 7311eb3b-aa29-4472-a4d7-8eea6c0868f0 | aae6d205-cfdd-4f5b-a61c-e5ef05a97cc3 |
| Pulmozyme | Pulmozyme | 88e44ee7-b7a1-4aee-b8e3-a7aa139a4cdc | 2275909f-b67d-4e57-8224-bead5c55e046 |
| RA Copay | Actemra | ee50b16e-aa22-4770-a2be-48d924c0b76c | b8bc2c4f-3baa-456f-84af-13414a52da2e |
| RA Copay | Rituxan | a3f1b8c8-c98a-41cd-8811-d71f85007265 | 5fdfb6d6-cfc5-41ed-9d3c-ac317291a38d |
| RA Copay | Rituxan Admin | 78f24040-b5c4-46f9-8942-ef9027e41697 | 21045343-07f3-4794-ba31-cfcea77823f0 |
| Xolair | Xolair Drug | 8afd5584-e738-4b01-94d9-5a60d9a0cab0 | fcb9d344-25a8-11ee-be56-0242ac120002 |
| Xolair | Xolair Admin | ef990cca-d6c7-4ddf-b652-f347b8af61b4 | 150e4c80-25f0-11ee-be56-0242ac120002 |
Each portfolio has a Master Group Number representing an overarching set of programs that could be assigned to one member ID and is located on the Copay Response bundle. This Master Group Number is used to process a claim at the pharmacy. It can be found on:
| Portfolio | Master Group Number |
|---|---|
| Actemra | EC38541004 |
| BioOncology | EC38548001 |
| Enspryng | EC38526001 |
| Esbriet | EC38523002 |
| Evrysdi | EC38525001 |
| Hemlibra | 99995209 |
| Ocrevus | EC38517002 |
| Ocrevus Zunovo | EC38517002 |
| Ophthalmology | EC38532001 |
| PiaSky | 99995273 |
| Pulmozyme | EC38516003 |
| Rituxan (Immunology) | EC38543004 |
| Xolair | 99995223 |
If patient has commercial or private insurance, then Insurance Plan Type is required field. If patient's plan is not listed, select 'Other' and provide plan type.
| Insurance Plan Type |
|---|
| CDHP Consumer-directed Health Plan |
| EPO Exclusive Provider Organization |
| FFS Fee for Service |
| HDHP High-deductible Health Plan |
| HMO Health Maintenance Organization |
| HRA Health Reimbursement Account |
| HSA Health Savings Account |
| Indemnity |
| POS Point of Service |
| PPO Preferred Provider Organization |
| Union |
| Other. If Other, provide plan type |
If patient has commercial or private insurance, then Insurance Company (payer) is a required field. If patient's insurance company is not listed, select 'Other' and provide insurance name.
| Insurance Companies |
|---|
| Aetna |
| Alliance Health |
| Amerihealth |
| Anthem |
| Assurant |
| Blue Cross |
| Blue Shield |
| BCBS |
| Cigna |
| Cox Health |
| First Choice |
| Geisinger |
| Harvard Pilgrim |
| Healthnet |
| Humana |
| Kaiser |
| Medco |
| Medica |
| Medical Mutual |
| Optima |
| Preferred One |
| Providence |
| Select Health |
| United Healthcare (UHC) |
| United Medical Resources (UMR) |
| Other. If Other, provide insurance company name |