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

Products Specifics

When enrolling for Access Solutions or Genentech Patient Foundation services, the following information may be required:

  • Prescription
  • HCP Signature

Prescriptions and HCP Signature Requirements

Both prescriptions and HCP signatures are required based on product and services requested:

  • not all products require a prescription
  • with a few exceptions, HCP signatures are required when products require a prescription

  • when requesting for Patient Foundation services:

    • a prescription is required for a product if Shipment Option = UPFRONT
    • an Upfront shipment option is when medicine is delivered to patient’s home, practice or site of treatment.
    • an HCP signature is always required regardless if a prescrption is provided.


Patient Foundation Shipment Option: Upfront or Replacement

  • An Upfront Shipment is when a product is shipped to a patient's home, practice or site of treatment and requires a prescription to be shipped.
  • When a patient has been treated with product stocked at the doctor's office or treatment facility, a Replacement Shipment is coordinated to replace the product. No prescription is required for these shipments.

Each product is designated a shipment model as follows:

Product Accepted Shipment Option
Actemra Intravenous Upfront or Replacement
Actemra Subcutaneous Upfront
Alecensa Upfront
Avastin Upfront or Replacement
Columvi Upfront or Replacement
Cotellic Upfront
Enspryng Upfront
Erivedge Upfront
Evrysdi Upfront
Gazyva Upfront or Replacement
Hemlibra Upfront or Replacement
Herceptin Upfront or Replacement
Herceptin Hylecta Upfront or Replacement
Itovebi Upfront
Kadcyla Upfront or Replacement
Lucentis Upfront or Replacement
LUNSUMIO Upfront or Replacement
Ocrevus Upfront or Replacement
Ocrevus Zunovo Upfront or Replacement
Perjeta Upfront or Replacement
PHESGO Upfront or Replacement
Polivy Upfront or Replacement
Pulmozyme Upfront
Rituxan for Immunology Upfront or Replacement
Rituxan for Oncology Upfront or Replacement
Rituxan Hycela Upfront or Replacement
Rozlytrek Upfront
Susvimo Upfront or Replacement
Tecentriq Upfront or Replacement
Tecentriq Hybreza Upfront or Replacement
VABYSMO Upfront or Replacement
Venclexta Upfront
Xolair Upfront or Replacement
Zelboraf Upfront


The following tables represent the HCP signature requirements and the prescription values available for each product.


Actemra Intravenous (Immunology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Prescriber, Practice, Site of Treatment


Prescription Values for Actemra Intravenous

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note Once every 2 weeks Once every 4 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(Up to 5 digits))		 Any number
(Up to 5 digits))		 Any number
(Up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 80 mg vial(s)
200 mg vial(s}
400 mg vial(s)		 80 mg vial(s)
200 mg vial(s)
400 mg vial(s)		 80 mg vial(s)
200 mg vial(s)
400 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 2 weeks Once every 4 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Actemra Intravenous


Actemra Subcutaneous (Immunology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Prescriber, Practice, Patient


Prescription Values for Actemra Subcutaneous

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note ACTPen 162mg Inject 162mg Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 162 162 162
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 1 - 3 any number
(Up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Week(s)
OR
Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 2 weeks
OR
Once a week		 Once every 2 weeks
OR
Once a week		 String (up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Actemra Subcutaneous


Alecensa (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber


Prescription Values for Alecensa

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 600 mg twice a day Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 600 Any number
(Up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 BID String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Alecensa


Avastin (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment


Prescription Values for Avastin

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once every 2 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 100 mg vial(s)
400 mg vial(s)		 100 mg vial(s)
400 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 2 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Avastin


COLUMVI (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for COLUMVI

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Ramp up Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value - Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense Quantity
(for multiple options)		 MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense Unit
(for multiple options)		 MedicationRequest.dispenseRequest.extension.extension.valueString 10 mg vial(s)
2.5 mg vial(s)		 10 mg vial(s)
2.5 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 - String
(up to 50 characters)
SIG MedicationRequest.dosageInstruction.text - -
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for COLUMVI


Cotellic (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber


Prescription Values for Cotellic

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 60 mg Daily Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 60 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 QD String
(up to 50 characters)
SIG MedicationRequest.dosageInstruction.text 60 mg Daily for 21 days on, followed by 7-day rest period. String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Cotellic


Enspryng (MS/NMO)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment


Prescription Values for Enspryng

Note: For Enspryng, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for BIPA SR		 Prescription Values
for BIPA SR		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text Loading Dose Maintenance Dose Loading Dose Maintenance Dose Maintenance Dose
Prescription Option MedicationRequest.note Inject 120 mg Inject 120 mg Inject 120 mg Inject 120 mg Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 120 120 120 120 120
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value - - - - 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Week(s) Month(s) Week(s) Month(s) Month(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value 3 1 3 1 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 120 mg 120 mg 120 mg 120 mg 120 mg
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Weeks 0, 2, 4 Every 4 Weeks Weeks 0, 2, 4 Every 4 Weeks -
SIG MedicationRequest.dosageInstruction.text Inject 120mg SQ at Weeks 0, 2, and 4 Inject 120mg SQ every 4 weeks Inject 120mg SQ at Weeks 0, 2, and 4 Inject 120mg SQ every 4 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 Any number
(up to 3 digits)		 0 Any number
(up to 3 digits)		 0 - 12

Medication Request Example for Enspryng


Erivedge (MS/NMO)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber


Prescription Values for Erivedge

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 150 mg Daily Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 150 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 QD String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Erivedge


Evrysdi (Rare Disease)

Vendors cannot request CoPay or Appeals SR via UAPI For Patient Foundation SR, eligibility reason must be uninsured for UAPI

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR N/A for UAPI N/A for UAPI  
Appeals SR N/A for UAPI N/A for UAPI  
Starter SR Yes Yes Patient, Practice, Prescriber
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber



Prescription Values for Evrysdi

Evrysdi uses a different version of the standard patient consent that requires a signature and date from the patient or authorized person.
Evrysdi Digital Consent Example


Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)		 Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		  
Prescription Type MedicationRequest.courseOfTherapyType.text 0.75mg/mL 80mL
(in 100mL bottle)		 0.75mg/mL 80mL
(in 100mL bottle)		 0.75mg/mL 80mL
(in 100mL bottle)		 Starter
(0.75mg/mL 80mL (in 100mL bottle))		 Starter
(0.75mg/mL 80mL (in 100mL bottle))		  
Prescription Option MedicationRequest.note 5 mg (6.6 mL)
once daily		 Other Other -
once daily		 5 mg (6.6 mL)
once daily		 Other -
once daily		  
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 5
6.6		 - Any number
(Up to 5 digits)

Any number
(Up to 5 digits)		 5
6.6		 Any number
(Up to 5 digits)

Any number
(Up to 5 digits)		  
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg
and
mL		 - mg
and
mL		 mg
and
mL		 mg
and
mL		  
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 29 1 - 29 1 - 29 1 - 29 1 - 29  
Dispense unit
 MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s) Month(s) Month(s)  
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 once daily - once daily once daily once daily  
SIG MedicationRequest.dosageInstruction.text - - String
(up to 50 characters)		 - - -
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 1 0 - 1  

Medication Request Example for Evrysdi


Gazyva (BioOncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Gazyva

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
(Option 4)
Prescription Type MedicationRequest.courseOfTherapyType.text - - - -
Prescription Option MedicationRequest.note Day 1, Day 8 and Day 15 Day 8 and Day 15 100 mg on Day 1, and 900 mg on Day 2 Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 1000 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.unit 1000 mg vial(s) 1000 mg vial(s) 1000 mg vial(s) 1000 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Day 1, Day 8 and Day 15 Day 8 and Day 15) - String
(up to 50 characters)
SIG MedicationRequest.dosageInstruction.text - - 100 mg on Day 1 and 900 mg on Day 2 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12

Medication Request Example for Gazyva


Hemlibra (Rare Disease)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Hemlibra when Patient Foundation SR is selected

Note: For Hemlibra, up to 2 prescriptions can be submitted, maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
(OPTION 4)
Prescription Type MedicationRequest.courseOfTherapyType.text Initial
Dose		 Initial
Dose		 Subsequent
Dose		 Subsequent
Dose		 Subsequent
Dose		 Subsequent
Dose
Prescription Option MedicationRequest.note 3-mg/kg Other 1.5-mg/kg 3-mg/kg 6-mg/kg Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 3 Any number
(Up to 5 digits)		 1.5 3 6 Any number
(Up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 1 1 1 1 1
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s) Month(s) Month(s) Month(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(Up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 - - - - - -
SIG MedicationRequest.dosageInstruction.text String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12



Prescription Values for Hemlibra when BIPA SR is selected

Note: For Hemlibra, up to 2 prescriptions can be submitted, maximum of 1 per Prescription Option

Field Name Resource-ElementID Prescription Values
for BIPA SR
(OPTION 1)		 Prescription Values
for BIPA SR
(OPTION 2)		 Prescription Values
for BIPA SR
(OPTION 1)		 Prescription Values
for BIPA SR
(OPTION 2)		 Prescription Values
for BIPA SR
(OPTION 3)		 Prescription Values
for BIPA SR
(OPTION 4)
Prescription Type MedicationRequest.courseOfTherapyType.text BIPA BIPA BIPA BIPA BIPA BIPA
Prescription Option MedicationRequest.note 30-day Initial Dose
(3mg/kg)		 30-day Initial Dose
(Other)		 30-day Subsequent Dose
(1.5mg/kg)		 30-day Subsequent Dose
(3-mg/kg)		 30-day Subsequent Dose
(6-mg/kg)		 30-day Subsequent Dose
(Other)
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 3 Any number
(Up to 5 digits)		 1.5 3 6 any number
(Up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 1 1 1 1 1
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s) Month(s) Month(s) Month(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.dispenseQuantity.value Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(Up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(Up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.dispenseUnit.valuestring 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)		 12mg vial(s)
30mg vial(s)
60mg vial(s)
105mg vial(s)
150mg vial(s)
300mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 - - - - - -
SIG MedicationRequest.dosageInstruction.text String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 0 0 0 0 0

Medication Request Example for Hemlibra


Herceptin (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Herceptin

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once every 3 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 150 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.unit 150 mg vial(s) 150 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 3 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Herceptin


Herceptin Hylecta (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Herceptin Hylecta

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 600 mg trastuzumab/10,000 units hyaluronidase Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 600 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.unit 600 mg vial(s) 600 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Herceptin Hylecta


Itovebi (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
Shipment Option = Upfront		 Yes Patient, Practice, Prescriber



Prescription Values for Itovebi

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 9 mg once daily 3 mg once daily
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 9 3
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 QD QD
SIG MedicationRequest.dosageInstruction.text String
(up to 150 characters)		 String
(up to 150 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

[Medication Request Example for Itovebi]




Kadcyla (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Kadcyla

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once every 3 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.unit 100 mg vial(s)
160 mg vial(s)		 100 mg vial(s)
160 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 3 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Kadcyla


Lucentis (Ophthalmology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Lucentis

Note: For Lucentis, up to 2 prescriptions can be submitted, maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text One Eye 0.3 mg One Eye 0.3 mg Both Eyes 0.3 mg Both Eyes 0.3 mg One Eye 0.5 mg One Eye 0.5 mg Both Eyes 0.5 mg Both Eyes 0.5 mg
Prescription Option MedicationRequest.note Inject 0.3 mg (0.05 mL)
intravitreally		 Other Inject 0.3 mg (0.05 mL)
intravitreally		 Other Inject 0.5 mg (0.05 mL)
intravitreally		 Other Inject 0.5 mg (0.05 mL) intravitreally Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 0.3 0.3 0.3 0.3 0.5 0.5 0.5 0.5
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)		 0.3 mg prefilled syringe(s)

0.5 mg prefilled syringe(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Monthly String
(up to 50 characters)		 Monthly String
(up to 50 characters)		 Monthly
OR
Monthly x4 then Quarterly
OR
Monthly x3 then PRN		 String
(up to 50 characters)		 Monthly
OR
Monthly x4 then Quarterly
OR
Monthly x3 then PRN		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12

Medication Request Example for Lucentis


Lunsumio (BioOncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Lunsumio

NOTE: For Lunsumio, up to 2 prescriptions can be submitted, maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text Cycle Cycle Cycle Other Other
Prescription Option MedicationRequest.note Cycle 1 -
Step Up Dosing		 Cycle 2 Cycles 3 - 17 Other -
1 mg vial(s)		 Other -
30 mg vial(s)
# of Tablets MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value - - - - -
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value - 60 30 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg
Dispense quantity
(for single option)		 MedicationRequest.dispenseRequest.quantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit
(for single option)		 MedicationRequest.dispenseRequest.quantity.unit 1 mg vial(s)
30 mg vial(s)		 1 mg vial(s)
30 mg vial(s)		 1 mg vial(s)
30 mg vial(s)		 1 mg vial(s)
30 mg vial(s)		 1 mg vial(s)
30 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 - - - - -
SIG MedicationRequest.dosageInstruction.text - 60 mg once on
Day 1 of Cycle 2		 once every 21 days
up to 14 cycles		 String
(up to 150 characters)		 String
(up to 150 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed - - 0 - 14 0 - 16 0 - 16

Medication Request Example for Lunsumio


Ocrevus (MS/NMO)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Ocrevus

Note: For Ocrevus, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation
(OPTION 1)		 Prescription Values
for Patient Foundation
(OPTION 2)		 Prescription Values
for Patient Foundation
(OPTION 1)		 Prescription Values
for Patient Foundation
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text Initial Dose Initial Dose Subsequent Dose Subsequent Dose
Prescription Option MedicationRequest.note Day 1 & Day 15 Other Every 6 months Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit 300 mg vial(s) 300 mg vial(s) 300 mg vial(s) 300 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Day 1 and Day 15 String
(up to 50 characters)		 Every 6 months String
(up to 50 characters)
SIG MedicationRequest.dosageInstruction.text String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12

Medication Request Example for Ocrevus


Ocrevus Zunovo

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR Yes Yes Practice, Prescriber, Site Of Treatment
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Ocrevus Zunovo

Note: For Ocrevus Zunovo, only 1 prescription can be submitted;

Field Name Resource-ElementID Prescription Values
for Starter
(OPTION 1)		 Prescription Values
for Patient Foundation
(OPTION 1)		 Prescription Values
for Patient Foundation
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text Starter Standard Standard
Prescription Option MedicationRequest.note Starting Pack Every 6 months Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 920 920 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit 920mg/23 ML vial(s) 920mg/23 ML vial(s) 920mg/23 ML vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		   Once every 6 months String
(up to 50 characters)
SIG MedicationRequest.dosageInstruction.text   String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 0 - 12 0 - 12

[Medication Request Example for Ocrevus Zunovo]


Perjeta (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Perjeta

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note 840 mg as Initial Dose Once every 3 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.unit 420 mg vial(s) 420 mg vial(s) 420 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once Once every 3 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 0 - 12 0 - 12

Medication Request Example for Perjeta


Phesgo (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Phesgo

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note 1200 mg pertuzumab/600 mg trastuzumab/30,000 units hyaluronidase 600 mg pertuzumab/600 mg trastuzumab/20,000 units hyaluronidase Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 1200 600 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.quantity.value Any number Any number Any number
Dispense unit MedicationRequest.dispenseRequest.quantity.value 1200mg
1800mg		 1200mg
1800mg		 1200mg
1800mg
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Phesgo


Polivy (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Polivy

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once Every 21 Days Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 30 mg vial(s)
140 mg vial(s)		 30 mg vial(s)
140 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 21 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Polivy


Pulmozyme (Respiratory)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Patient



Prescription Values for Pulmozyme

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
Prescription Type MedicationRequest.courseOfTherapyType.text -
Prescription Option MedicationRequest.note 2.5 mL Inhalation Solution
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 2.5
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mL
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 QD or BID
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12

Medication Request Example for Pulmozyme


Rituxan Hycela (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Rituxan Hycela

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
(OPTION 4)		 Prescription Values
for Patient Foundation SR
(OPTION 5)
Prescription Type MedicationRequest.courseOfTherapyType.text - - - - -
Prescription Option MedicationRequest.note Every 2 Months Every 21 Days Every 28 Days Other Weekly
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits))		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 1400 mg vial(s)
1600 mg vial(s)		 1400 mg vial(s)
1600 mg vial(s)		 1400 mg vial(s)
1600 mg vial(s)		 1400 mg vial(s)
1600 mg vial(s)		 1400 mg vial(s)
1600 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Every 2 Months Every 21 Days Every 28 Days String
(up to 50 characters)		 Weekly
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12

Medication Request Example for Rituxan Hycela


Rituxan for Immunology (Rheumatology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Rituxan for Immunology

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note Day 1 and Day 15 Once a week for 4 week Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 100 mg vial(s)
500 mg vial(s)		 100 mg vial(s)
500 mg vial(s)		 100 mg vial(s)
500 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Day 1 and Day 15 Once a week String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Rituxan for Immunology


Rituxan for Oncology (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Rituxan for Oncology

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once a week for 3 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 100 mg vial(s)
500 mg vial(s)		 100 mg vial(s)
500 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once a week String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Rituxan for Oncology


Rozlytrek (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber



Prescription Values for Rozlytrek

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 600 mg once daily Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 600 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Months(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 QD String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Rozlytrek


Susvimo (Opthalmology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Susvimo

Note: For Susvimo, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text Implant Kit Refill Kit
Prescription Option MedicationRequest.note Once every 24 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 2 2
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString Ocular Implant with Insertion Tool
2 mg (+ initial fill needle) vial(s)
2 mg (+ refill needle) vial(s)		 Ocular Implant with Insertion Tool
2 mg (+ initial fill needle) (vial(s)
2 mg (+ refill needle) vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 24 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Susvimo


Tecentriq (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Tecentriq

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note Once every 3 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 840 mg vial(s)
1200 mg vial(s)		 840 mg vial(s)
1200 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 3 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

Medication Request Example for Tecentriq


Tecentriq Hybreza (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Tecentriq Hybreza

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text - -
Prescription Option MedicationRequest.note 1875 mg atezolizumab and 30,000 units hyaluronidase per 15 mL Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 1875 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 1875 mg vial(s) 1875 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every 3 weeks String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12

[Medication Request Example for Tecentriq Hybreza]


Vabysmo (Opthalmology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR No No N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Practice, Prescriber, Site Of Treatment



Prescription Values for Vabysmo

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note Once every 4 weeks Once every 16 weeks Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 6 6 6
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit 6 mg vial(s) 6 mg vial(s) 6 mg vial(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 String
(up to 50 characters)		 String
(up to 50 characters)		 String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Vabysmo


Venclexta (Oncology)

Venclexta uses a separate version of the standard patient consent that requires a signature and date from the patient or authorized person.
Venclexta Patient Consent Example


Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR Yes Yes N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber



Prescription Values for Venclexta when Patient Foundation or BIPA SR is selected

Note: For Venclexta, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
Prescription Type MedicationRequest.courseOfTherapyType.text CLL/SLL
(Maint)		 AML
(Maint)		 Other Dosing
(Maint)		 AML
(Ramp-up)		 Other Dosing
(Ramp-up)		 CLL/SLL
(Start)
Prescription Option MedicationRequest.note Maintenance Maintenance Maintenance Ramp-up
Dosing		 Ramp-up
Dosing		 Starting
Pack
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Dosage (Day:1)
Dosage (Day:2)
Dosage (Day:3)
String
(up to 5 digits for each Day Dosage)		 Any number
(up to 5 digits)		 -
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg -
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 1 1 3 1 1
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s) Day(s) Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Daily Daily Daily Daily - -
SIG MedicationRequest.dosageInstruction.text - - - - String
(up to 150 characters)		 -
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 1 0 - 1 0 - 1 0 0 - 1 0



Prescription Values for Venclexta when Starter SR is selected

Note: For Venclexta, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type

Field Name Resource-ElementID Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		 Prescription Values
for Starter SR
(OPTION 3)		 Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		 Prescription Values
for Starter SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text Starter
(CLL/SLL)
Maint		 Starter
(AML)
Maint		 Starter
(Other) Dosing
Maint		 Starter
(AML)
Ramp-up		 Starter
(Other Dosing)
Ramp-up		 Starter
(CLL/SLL)
Start)
Prescription Option MedicationRequest.note Maintenance Maintenance Maintenance Ramp-up
Dosing		 Ramp-up
Dosing		 Starting
Pack
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Dosage (Day:1)
Dosage (Day:2)
Dosage (Day:3)
String
(up to 5 digits for each Day Dosage)		 Any number
(up to 5 digits)		 -
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg -
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 1 1 3 1 1
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s) Day(s) Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Daily Daily Daily Daily - -
SIG MedicationRequest.dosageInstruction.text - - - - String
(up to 150 characters)		 -
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 1 0 - 1 0 - 1 0 0 - 1 0

Medication Request Example for Venclexta


Xolair (Respiratory)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Optional N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR Yes Yes Patient, Practice, Prescriber, Site of Treatment
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber, Site of Treatment



Prescription Values for Xolair when Patient Foundation or BIPA SR is selected for Allergic Asthma (Vial/Prefilled Syringe/Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 4)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 5)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 6)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 7)
Prescription Type MedicationRequest.courseOfTherapyType.text Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Allergic Asthma (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note 75 mg/dose
every 4
weeks		 150 mg/dose
every 4
weeks		 225 mg/dose
every 2
weeks		 225 mg/dose
every 4
weeks		 300 mg/dose
every 2
weeks		 300 mg/dose
every 4
weeks		 375 mg/dose
every 2
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 225 225 300 300 375
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12



Prescription Values for Xolair when Patient Foundation or BIPA SR is selected for CSU (Vial/Prefilled Syringe/Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text CSU (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 CSU (Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note 150 mg/dose
every 4
weeks		 300 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 150 300
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12



Prescription Values for Xolair when Patient Foundation or BIPA SR is selected for Nasal Polyps (Vial / Prefilled Syringe / Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 4)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 5)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 6)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 7)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 8)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 9)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 10)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 11)
Prescription Type MedicationRequest.courseOfTherapyType.text Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Nasal Polyps
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note 75 mg/dose
every 4
weeks		 150 mg/dose
every 4
weeks		 225 mg/dose
every 4
weeks		 300 mg/dose
every 2
weeks		 300 mg/dose
every 4
weeks		 375 mg/dose
every 2
weeks		 450 mg/dose
every 2
weeks		 450 mg/dose
every 4
weeks		 525 mg/dose
every 2
weeks		 600 mg/dose
every 2
weeks		 600 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 225 300 300 375 450 450 525 600 600
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12



Prescription Values for Xolair when Patient Foundation or BIPA SR is selected for Food Allergy (Vial / Prefilled Syringe / Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 4)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 5)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 6)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 7)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 8)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 9)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 10)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 11)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 12)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 13)
Prescription Type MedicationRequest.courseOfTherapyType.text Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))		 Food Allergy
(Prefilled Syringe)
OR
(Vial)
OR
(Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note 75 mg/dose
every 4
weeks		 150 mg/dose
every 4
weeks		 150 mg/dose
every 2
weeks		 225 mg/dose
every 2
weeks		 225 mg/dose
every 4
weeks		 300 mg/dose
every 2
weeks		 300 mg/dose
every 4
weeks		 375 mg/dose
every 2
weeks		 450 mg/dose
every 2
weeks		 450 mg/dose
every 4
weeks		 525 mg/dose
every 2
weeks		 600 mg/dose
every 2
weeks		 600 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 150 225 225 300 300 375 450 450 525 600 600
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12 0 - 12



Prescription Values for Xolair when Starter SR is selected for Allergic Asthma OR CSU (Prefilled Syringe or Vial or Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		 Prescription Values
for Starter SR
(OPTION 3)		 Prescription Values
for Starter SR
(OPTION 4)		 Prescription Values
for Starter SR
(OPTION 5)		 Prescription Values
for Starter SR
(OPTION 6)		 Prescription Values
for Starter SR
(OPTION 7)		 Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)
Prescription Type MedicationRequest.courseOfTherapyType.text Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note Allergic Asthma -
75 mg/dose
every 4
weeks		 Allergic Asthma -
150 mg/dose
every 4
weeks		 Allergic Asthma -
225 mg/dose
every 2
weeks		 Allergic Asthma -
225 mg/dose
every 4
weeks		 Allergic Asthma -
300 mg/dose
every 2
weeks		 Allergic Asthma -
300 mg/dose
every 4
weeks		 Allergic Asthma -
375 mg/dose
every 2
weeks		 CSU -
150 mg/dose
every 4
weeks		 CSU -
300 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 225 225 300 300 375 150 300
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 1 1 1 1 1 1 1 1 1



Prescription Values for Xolair when Starter SR is selected for Nasal Polyps (Prefilled Syringe or Vial or Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		 Prescription Values
for Starter SR
(OPTION 3)		 Prescription Values
for Starter SR
(OPTION 4)		 Prescription Values
for Starter SR
(OPTION 5)		 Prescription Values
for Starter SR
(OPTION 6)		 Prescription Values
for Starter SR
(OPTION 7)		 Prescription Values
for Starter SR
(OPTION 8)		 Prescription Values
for Starter SR
(OPTION 9)		 Prescription Values
for Starter SR
(OPTION 10)		 Prescription Values
for Starter SR
(OPTION 11)
Prescription Type MedicationRequest.courseOfTherapyType.text Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		  
Prescription Option MedicationRequest.note Nasal Polyps -
75 mg/dose
every 4
weeks		 Nasal Polyps -
150 mg/dose
every 4
weeks		 Nasal Polyps -
225 mg/dose
every 4
weeks		 Nasal Polyps -
300 mg/dose
every 2
weeks		 Nasal Polyps -
300 mg/dose
every 4
weeks		 Nasal Polyps -
375 mg/dose
every 2
weeks		 Nasal Polyps -
450 mg/dose
every 2
weeks		 Nasal Polyps -
450 mg/dose
every 4weeks		 Nasal Polyps -
525 mg/dose
every 2
weeks		 Nasal Polyps -
600 mg/dose
every 2
weeks		 Nasal Polyps -
600 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 225 300 300 375 450 450 525 600 600
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 1 1 1 1 1 1 1 1 1 1 1



Prescription Values for Xolair when Starter SR is selected for Food Allergy (Prefilled Syringe or Vial or Autoinjector (≥12 years old))

Field Name Resource-ElementID Prescription Values
for Starter SR
(OPTION 1)		 Prescription Values
for Starter SR
(OPTION 2)		 Prescription Values
for Starter SR
(OPTION 3)		 Prescription Values
for Starter SR
(OPTION 4)		 Prescription Values
for Starter SR
(OPTION 5)		 Prescription Values
for Starter SR
(OPTION 6)		 Prescription Values
for Starter SR
(OPTION 7)		 Prescription Values
for Starter SR
(OPTION 8)		 Prescription Values
for Starter SR
(OPTION 9)		 Prescription Values
for Starter SR
(OPTION 10)		 Prescription Values
for Starter SR
(OPTION 11)		 Prescription Values
for Starter SR
(OPTION 12)		 Prescription Values
for Starter SR
(OPTION 13)
Prescription Type MedicationRequest.courseOfTherapyType.text Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))		 Starter (Prefilled Syringe)
OR
Starter (Vial)
OR
Starter (Autoinjector (≥12 years old))
Prescription Option MedicationRequest.note 75 mg/dose
every 4
weeks		 150 mg/dose
every 4
weeks		 150 mg/dose
every 2
weeks		 225 mg/dose
every 2
weeks		 225 mg/dose
every 4
weeks		 300 mg/dose
every 2
weeks		 300 mg/dose
every 4
weeks		 375 mg/dose
every 2
weeks		 450 mg/dose
every 2
weeks		 450 mg/dose
every 4
weeks		 525 mg/dose
every 2
weeks		 600 mg/dose
every 2
weeks		 600 mg/dose
every 4
weeks
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 75 150 150 225 225 300 300 375 450 450 525 600 600
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg mg mg mg mg mg mg mg mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90		 30
OR
90
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s) Day(s)
Dispense quantity MedicationRequest.dispenseRequest.extension.extension.valueQuantity.value Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)		 Any number
(up to 5 digits)
Dispense unit MedicationRequest.dispenseRequest.extension.extension.valueString 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)		 150 mg vial(s)
150 mg prefilled syringe(s)
150 mg autoinjector(s)
300 mg prefilled syringe(s)
300 mg autoinjector(s)
75 mg prefilled syringe(s)
75 mg autoinjector(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 Once every
4 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks		 Once every
2 weeks		 Once every
2 weeks		 Once every
4 weeks
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 1 1 1 1 1 1 1 1 1 1 1 1 1



Medication Request Example for Xolair


Zelboraf (Oncology)

Service Request Type Is Prescription Required? Is HCP Signature Required? Ship To Options
BIPA SR Yes Yes N/A
CoPay SR No No N/A
Appeals SR No No N/A
Starter SR N/A N/A N/A
Patient Foundation SR Yes
only if Shipment Option = Upfront		 Yes Patient, Practice, Prescriber



Prescription Values for Zelboraf

Field Name Resource-ElementID Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 1)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 2)		 Prescription Values
for Patient Foundation SR
OR
BIPA SR
(OPTION 3)
Prescription Type MedicationRequest.courseOfTherapyType.text - - -
Prescription Option MedicationRequest.note 960 mg Twice a day 960 mg twice daily for 21, 720 mg twice daily thereafter Other
Dosage MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value 960 960 Any number
(up to 5 digits)
Dosage unit MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit mg mg mg
Dispense quantity MedicationRequest.dispenseRequest.expectedSupplyDuration.value 1 - 3 1 - 3 1 - 3
Dispense unit MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit Month(s) Month(s) Month(s)
Frequency of administration MedicationRequest.dosageInstruction.Timing
OR
MedicationRequest.dosageInstruction.PatientInstructions		 BID BID String
(up to 50 characters)
Refill(s) MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed 0 - 12 0 - 12 0 - 12

Medication Request Example for Zelboraf