Access Solutions Enrollment Experience UAPI
Business Description - Old
Services Offered
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
The following services are offered by Access Solutions and the Genentech Patient Foundation:
Benefits Investigation/Prior Authorization (BIPA Service Request) can be conducted to determine:
- if a Genentech medicine is covered. For BioOncology enrollments, benefits investigation includes regimen products investigation.
- If a Prior Authorization is required and helps identify the required forms and documents for your submission to the health insurance plan.
- If patient assistance might be needed.
Appeals Support (Appeals Service Request)
Access Solutions can provide resources as you prepare an appeal submission, per your patient’s plan requirements.
Referral for Copay Assistance Service Request (CoPay Service Request)
Co-pay referral services are designed to help patients who cannot afford to pay their insurance Co-payments. If publicly insured patients have difficulty paying for their Genentech product’s Co-pay or co-insurance, Access Solutions can refer them to an Independent Co-pay Assistance Foundation supporting their disease state.
Note: The Referral for CoPay Assistance Service Request administered by Access Solutions is different from the CoPay Card program administered by ConnectiveRX.
Starter Program (Starter Service Request)
Access Solutions offers Starter Program kits for several products (refer to Genentech Products table under Prescriptions section). If eligible, allows patients to start treatment during the reimbursement process.
Patient Foundation (Patient Foundation Service Request)
The Genentech Patient Foundation gives free Genentech medicine to people who don’t have insurance coverage or who have financial concerns and meet certain eligibility criteria. Learn more about the Genentech Patient Foundation.
Services Provided by Products
All Access Solutions and Patient Foundation services are available for all products except Starter Program services are available only for the following products:
- Actemra Subcutaneous
- Alecensa
- Esbriet
- Evrysdi
- Gavreto
- Hemlibra
- Rozlytrek
- Venclexta
- Xolair
Prescriptions
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
When are prescriptions required?
HCP prescriptions are required based on product, enrollment type and services requested.
- For Access Solutions (AS) enrollments: not all products require a prescription; Starter SRs are not applicable for all products (indicated with a ‘-’ in table below).
- For Genentech Patient Foundation (GPF) enrollments, a prescription is required for a product if Shipment Option = Upfront.
| Product | Therapeutic Area | GPF Enrollment: Prescription Required (if Shipment Option = Upfront) | AS Enrollment: Prescription Required for a Benefits Investigation/Prior Authorization (BIPA SR) | AS Enrollment: Prescription Required for a Starter Program (Starter SR) |
|---|---|---|---|---|
| Actemra Intravenous | Immunology | Yes | No | - |
| Actemra Subcutaneous | Immunology | Yes | Yes | Yes |
| Alecensa | Oncology | Yes | Yes | Yes |
| Avastin | Oncology | Yes | No | - |
| Cotellic | Oncology | Yes | Yes | - |
| Enspryng | MS/NMO | Yes | Yes | - |
| Erivedge | Oncology | Yes | Yes | - |
| Esbriet | Respiratory | Yes | No | Yes |
| Evrysdi | Rare Disease | Yes | Yes | Yes |
| Gavreto | Oncology | Yes | Yes | Yes |
| Gazyva | Oncology | Yes | No | - |
| Hemlibra | Rare Disease | Yes | No | Yes |
| Herceptin | Oncology | Yes | No | - |
| Herceptin Hylecta | Oncology | Yes | No | - |
| Kadclya | Oncology | Yes | No | - |
| Lucentis | Ophthalmology | Yes | No | - |
| Ocrevus | MS/NMO | Yes | Yes | - |
| Perjeta | Oncology | Yes | No | - |
| Phesgo | Oncology | Yes | No | - |
| Polivy | Oncology | Yes | No | - |
| Pulmozyme | Respiratory | Yes | No | - |
| Rituxan for Immunology | Immunology | Yes | No | - |
| Rituxan for Oncology | Oncology | Yes | No | - |
| Rituxan Hycela | Oncology | Yes | No | - |
| Rozlytrek | Oncology | Yes | Yes | Yes |
| Susvimo | Ophthalmology | Yes | No | - |
| Tecentriq | Oncology | Yes | No | - |
| Venclexta | Oncology | Yes | Yes | Yes |
| Xeloda | Oncology | Yes | Yes | - |
| Xolair | Respiratory | Yes | Yes | Yes |
| Zelboraf | Oncology | Yes | Yes | - |
When is an HCP signature required?
HCP signatures are required based on product, enrollment type and services requested.
- For Access Solutions (AS) enrollments: With a few exceptions, for the most part HCP signatures are required when products require a prescription
- For Genentech Patient Foundation (GPF) enrollments: an HCP signature is required when a prescription is required for a product
| Product | Therapeutic Area | GPF Enrollment: HCP Signature Required (Only if Shipment Option = Upfront) | AS Enrollment: If HCP Signature Required, Service Request Type |
|---|---|---|---|
| Actemra Intravenous | Immunology | Yes | - |
| Actemra Subcutaneous | Immunology | Yes | Starter |
| Alecensa | Oncology | Yes | BIPA Starter |
| Avastin | Oncology | Yes | - |
| Cotellic | Oncology | Yes | BIPA |
| Enspryng | MS/NMO | Yes | - |
| Erivedge | Oncology | Yes | BIPA |
| Esbriet | Respiratory | Yes | Starter |
| Evrysdi | Rare Disease | Yes | BIPA Starter |
| Gavreto | Oncology | Yes | BIPA Starter |
| Gazyva | Oncology | Yes | - |
| Hemlibra | Rare Disease | Yes | Starter |
| Herceptin | Oncology | Yes | - |
| Herceptin Hylecta | Oncology | Yes | - |
| Kadclya | Oncology | Yes | - |
| Lucentis | Ophthalmology | Yes | - |
| Ocrevus | MS/NMO | Yes | Optional for BIPA |
| Perjeta | Oncology | Yes | - |
| Phesgo | Oncology | Yes | - |
| Polivy | Oncology | Yes | - |
| Pulmozyme | Respiratory | Yes | - |
| Rituxan for Immunology | Immunology | Yes | - |
| Rituxan for Oncology | Oncology | Yes | - |
| Rituxan Hycela | Oncology | Yes | - |
| Rozlytrek | Oncology | Yes | BIPA Starter |
| Susvimo | Ophthalmology | Yes | - |
| Tecentriq | Oncology | Yes | - |
| Venclexta | Oncology | Yes | BIPA Starter |
| Xeloda | Oncology | Yes | BIPA |
| Xolair | Respiratory | Yes | Optional for BIPA Required for Starter SR |
| Zelboraf | Oncology | Yes | BIPA |
Regimen Products
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
Regimen products are non-Genentech products that can be used in combination with Genentech Oncology products for a regimen benefits investigation.
- Regimen products are available in combination with Genentech Oncology products only and are not required in order for an HCP to prescribe a Genentech oncology product.
- Regimen products are available only for Access Solutions enrollments and are not available for Patient Foundation enrollments.
- If Benefits Investigation/Prior Authorization (BIPA) services are selected, regimen products are included in the benefits investigation and the results are provided in the status update. Query Message Request
- HCP signature is not required for regimen products.
Validation API
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
- Patient Consent Only
A validation API has been implemented on the Access Solutions/Genentech Patient Foundation (AS/GPF) side to ensure that enrollments have the minimum required information to process enrollments.
If an enrollment is missing any of the listed resources and/or data elements, the enrollment is rejected, meaning the bundle is not processed by AS/GPF. Our external partner will receive a message indicating that an error has occurred and a transaction ID and info on what data is missing will also be provided. If multiple resources/data elements are missing, error message will list all missing resources/fields. The external partner will be responsible for resubmitting enrollment with the missing information in order for enrollment to be processed.
| Resource | Access Solutions (AS) Enrollment | Genentech Patient Foundation (GPF) Enrollment |
|---|---|---|
| Patient | Required | Required |
| MedicationRequest | Required | Required |
| Condition | Required | Required |
| ServiceRequest | Required | Required |
| Practitioner | Required | Required |
| Resource | Data Element | Access Solutions (AS) Enrollment | Genentech Patient Foundation (GPF) Enrollment |
|---|---|---|---|
| Patient | Patient First Name | Required | Required |
| Patient | Patient Last Name | Required | Required |
| Patient | Date of Birth | Required | Required |
| Patient | Street Address | Required | Required |
| Patient | City | Required | Required |
| Patient | State | Required | Required |
| Patient | Zip | Required | Required |
| Patient | Phone | Required | Required |
| Patient | Phone Type | Required | Required |
| Patient | Preferred Language | Required | Required |
| MedicationRequest | Product | Required | Required |
| Condition | Diagnosis Code | Required | Required |
| ServiceRequest | ServiceRequest Type | Required | Required |
| Practitioner | Prescriber First Name | Required | Required |
| Practitioner | Prescriber Last Name | Required | Required |
| Practitioner | Prescriber NPI# | Required | Required |
| Organization | Prescriber Street Address | Required | Required |
| Organization | Prescriber City | Required | Required |
| Organization | Prescriber State | Required | Required |
| Organization | Prescriber Zip | Required | Required |
| Organization | Practice Name | Required | Required |
| Organization | Practice Contact First Name | Required | Required |
| Organization | Practice Contact Last Name | Required | Required |
| Organization | Practice Contact Phone# | Required | Required |
| Organization | Payer Name | Required | Optional |
| Coverage | Subscriber ID | Required | Optional |
| Coverage | First Name | Required | Optional |
| Coverage | Last Name | Required | Optional |
| Provenance | Prescriber signature | Conditional, based on product & Service Request Type | Required if Shipment Option = UPFRONT |
| Provenance | Prescriber signature date | Required if signature provided | Required if signature provided |
| Provenance | Patient signature | Required if Patient Consent is included in bundle | Required if Patient Consent is included in bundle |
| Provenance | Patient consent date | Required if Patient Consent is included in bundle | Required if Patient Consent is included in bundle |
| Consent | Patient consent (type) | Required if Patient Consent is included in bundle | Required if Patient Consent is included in bundle |
| Provenance | Signature type | Required if prescriber or patient signature is included in bundle | Required if prescriber or patient signature is included in bundle |
List of Possible Validation Error Messages that Can be Received
| Error Message Description | Expression |
|---|---|
| Missing required resource: Condition | Condition |
| Too many Condition resources found in the bundle, should be just one | Condition |
| Missing ICD10 code in Condition resource | Condition.code.coding.code |
| Missing Patient Authorization Signature Consent | Consent |
| Missing required resource: Coverage | Coverage |
| Missing payor references | Coverage.payor |
| Missing subscriber reference | Coverage.subscriber |
| Missing reference for Patient | Coverage.subscriber.reference |
| Missing Patient reference for | Coverage.subscriber.reference |
| Missing reference for RelatedPerson | Coverage.subscriber.reference |
| Missing Related Person reference for + reference | Coverage.subscriber.reference |
| Wrong subscriber type | Coverage.subscriber.type |
| Missing required field: subscriberId for Coverage: + coverageId | Coverage.subscriberId |
| Missing required resource: MedicationRequest | MedicationRequest |
| Missing Prescription information on MedicationRequest | MedicationRequest.note |
| Missing required resource: Organization | Organization |
| Organization referenced under Coverage.payor is not provided in the bundle | Organization |
| Missing required resource: Organization | Organization |
| Missing Organization address | Organization.address |
| Missing Organization city | Organization.address.city |
| Missing Organization country | Organization.address.country |
| Missing Organization address line | Organization.address.line |
| Missing Organization address line, only Organization Address.Apt/Unit found | Organization.address.line |
| Missing Organization postal code | Organization.address.postalCode |
| Missing Organization state | Organization.address.state |
| Wrong Organization state | Organization.address.state |
| Missing required field: contact | Organization.contact |
| Wrong amount of contact fields in Organization resource, should be 1 | Organization.contact |
| Missing Organization.contact's LastName | Organization.contact.name.family |
| Missing Organization.contact's FirstName | Organization.contact.name.given |
| Patient.managingOrganization.reference doesn't match Organization FullURL | Organization.FullURL |
| Missing required field: Payer name | Organization.Name |
| Missing Organization fax number | Organization.telecom.value |
| Wrong fax number format | Organization.telecom.value |
| Missing Organization phone number | Organization.telecom.value |
| Wrong Organization phone number format | Organization.telecom.value |
| Missing Patients | Patient |
| Missing required resource: Patient | Patient |
| Too many Patient resources found in Bundle: + numberOfPatients + , required only 1 | Patient |
| Missing Patient address | Patient.address |
| Missing Patient city | Patient.address.city |
| Missing Patient country | Patient.address.country |
| Missing Patient address line | Patient.address.line |
| Missing Patient address line, only Patient Address.Apt/Unit found | Patient.address.line |
| Missing Patient postal code | Patient.address.postalCode |
| Missing Patient state | Patient.address.state |
| Wrong Patient state | Patient.address.state |
| Missing required field: birthDate | Patient.birthDate |
| Patient's date of birth should be in the past | Patient.birthDate |
| Missing required reference to Practitioner | Patient.generalPractitioner.reference |
| Missing required reference to Organization | Patient.managingOrganization.reference |
| Missing required fields: FirstName, LastName | Patient.name |
| Missing Patient's LastName | Patient.name.family |
| Missing Patient's FirstName | Patient.name.given |
| Missing Patient phone number | Patient.telecom.value |
| Wrong Patient phone number format | Patient.telecom.value |
| Missing required resource: Practitioner | Practitioner |
| Too many Practitioner resources found in Bundle: ' + bundle.practitioners.size() + ', required only 1 | Practitioner |
| Patient.generalPractitioner.reference doesn't match Practitioner FullURL | Practitioner.FullURL |
| Missing required field: Identifier | Practitioner.identifier |
| Missing appropriate Practitioner's identifier type, required: 'National Provider Identifier' | Practitioner.identifier.type |
| Practitioner's NPI number doesn't have correct number of digits: ' + singleIdentifier.value.length() + ', required 10 | Practitioner.identifier.value |
| Practitioner's NPI number requires only digits, letters are forbidden | Practitioner.identifier.value |
| Missing Practitioner's NPI number | Practitioner.identifier.value |
| Missing required fields: FirstName, LastName | Practitioner.name |
| Missing Practitioner's LastName | Practitioner.name.family |
| Missing Practitioner's FirstName | Practitioner.name.given |
| Missing required resource: Provenance | Provenance |
| Missing Prescriber signature | Provenance.signature |
| Missing required values: + One or two missing links | Questionnaire/QuestionnaireResponse |
| Missing Related person | RelatedPerson |
| Missing required fields: FirstName, LastName | RelatedPerson.name |
| Missing Related Person's FirstName | RelatedPerson.name.given |
| Missing Related Person's LastName | RelatedPerson.name.family |
Questionnaires
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
- Patient Consent Only
What are Questionnaires?
Questionnaires consist of:
| Type | Example | Other Characteristics | When are they asked? |
|---|---|---|---|
| Medical attestation questions (MAQ) | Metastatic non-small cell lung cancer (NSCLC)? | - Product specific - Linked to a Service Request type | Enrolling a patient for Access Solution or Genentech Patient Foundation services |
| Non-clinical questions | Ok to send a text message? | - Not product specific - Linked to a Patient | - Enrolling a patient for Access Solution or Genentech Patient Foundation services - Submitting Patient Consent information |
| Metadata questions | 'Applied for BIPA?' | - Enrolling a patient for Access Solution or Genentech Patient Foundation services - Submitting Patient Consent information |
How to Access Questionnaires
Questionnaires are accessed by external partners by requesting Questionnaire definitions from GNE FHIR Server. Based on product, service request type, and version number, GNE will respond back with questionnaires that are specific for that product.
Questionnaire Response: Vendor will include response to the questionnaires in the bundle utilizing the QuestionnaireResponse resource.
Prescriptions by Product
Applicable for Use Case(s):
- Patient Enrollment with Patient Consent
- Patient Enrollment Only
Prescription options for Alecensa
| Product | Therapeutic Area | 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 Starter SR |
|---|---|---|---|---|---|---|
| Alecensa | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | Starter |
| Alecensa | Oncology | Prescription Option | MedicationRequest.Notes | 600 mg twice a day | Other | 600 mg twice/day |
| Alecensa | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 600 | any number (up to 5 characters) | 600 |
| Alecensa | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Alecensa | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | 1 - 3 | 1 |
| Alecensa | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Months(s) | Months(s) | Months(s) |
| Alecensa | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | BID | String (up to 50 characters) | BID |
| Alecensa | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 1 |
Prescription options for Avastin
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Avastin | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Avastin | Oncology | Prescription Option | MedicationRequest.Notes | Once every 2 weeks | Other |
| Avastin | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number up to 5 characters) |
| Avastin | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Avastin | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Avastin | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 100 mg vial(s) OR 400 mg vial(s) | 100 mg vial(s) OR 400 mg vial(s) |
| Avastin | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 2 weeks | String (up to 50 characters) |
| Avastin | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Cotellic
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|
| Cotellic | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Cotellic | Oncology | Prescription Option | MedicationRequest.Notes | 60 mg Daily | Other |
| Cotellic | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 60 | any number up to 5 characters) |
| Cotellic | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Cotellic | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | 1 - 3 |
| Cotellic | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Month(s) | Month(s) |
| Cotellic | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | QD | String (up to 50 characters) |
| Cotellic | Oncology | SIG | MedicationRequest.dosageInstruction.text | 60 mg Daily for 21 days on, followed by 7-day rest period. | String (up to 50 characters) |
| Cotellic | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Erivedge
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|
| Erivedge | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Erivedge | Oncology | Prescription Option | MedicationRequest.Notes | 150 mg Daily | Other |
| Erivedge | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 150 | any number (up to 5 characters) |
| Erivedge | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Erivedge | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | any number (up to 5 characters) |
| Erivedge | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Month(s) | Month(s) |
| Erivedge | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | QD | String (up to 50 characters) |
| Erivedge | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Gavreto
| Product | Therapeutic Area | 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 Starter SR (Option 1) | Prescription Values for Starter SR (Option 2) |
|---|---|---|---|---|---|---|---|
| Gavreto | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | Starter | Starter |
| Gavreto | Oncology | Prescription Option | MedicationRequest.Notes | 400 mg once daily | Other | 400 mg once daily | Other |
| Gavreto | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 400 | any number (up to 5 characters) | 400 | any number (up to 5 characters) |
| Gavreto | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg |
| Gavreto | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | 1 - 3 | 1 | 1 |
| Gavreto | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Months(s) | Months(s) | Months(s) | Months(s) |
| Gavreto | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | once daily | String (up to 50 characters) | once daily | String (up to 50 characters) |
| Gavreto | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 1 | 0 - 1 |
Prescription options for Gazyva
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|---|
| Gazyva | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - | - |
| Gazyva | Oncology | Prescription Option | MedicationRequest.Notes | Day 1, Day 8 and Day 15 | Day 8 and Day 15 | 100 mg on Day 1, and 900 mg on Day 2 | Other |
| Gazyva | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number(up to 5 characters) | any number (up to 5 characters) | 1000 | any number (up to 5 characters) |
| Gazyva | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg |
| Gazyva | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number | Any number |
| Gazyva | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Months(s) | Months(s) | Months(s) | Months(s) |
| Gazyva | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | once daily | String (up to 50 characters) | once daily | String (up to 50 characters) |
| Gazyva | Oncology | SIG | MedicationRequest.dosageInstruction.text | - | - | 100 mg on Day 1 and 900 mg on Day 2 | String (up to 50 characters) |
| Gazyva | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 1 | 0 - 1 |
Prescription options for Herceptin
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Herceptin | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Herceptin | Oncology | Prescription Option | MedicationRequest.Notes | Once every 3 weeks | Other |
| Herceptin | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 150 | any number (up to 5 characters) |
| Herceptin | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Herceptin | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Herceptin | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 150 mg vial(s) | 150 mg vial(s) |
| Herceptin | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 3 weeks | String (up to 50 characters) |
| Herceptin | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Herceptin Hylecta
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Herceptin Hylecta | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Herceptin Hylecta | Oncology | Prescription Option | MedicationRequest.Notes | 600 mg trastuzumab/10,000 units hyaluronidase | Other |
| Herceptin Hylecta | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 600 | any number (up to 5 characters) |
| Herceptin Hylecta | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Herceptin Hylecta | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Herceptin Hylecta | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 600 mg vial(s) | 600 mg vial(s) |
| Herceptin Hylecta | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | String (up to 50 characters) | String (up to 50 characters) |
| Herceptin Hylecta | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Kadcyla
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Kadcyla | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Kadcyla | Oncology | Prescription Option | MedicationRequest.Notes | Once every 3 weeks | Other |
| Kadcyla | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) |
| Kadcyla | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Kadcyla | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Kadcyla | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 100 mg vial(s) 160 mg vial(s) | 100 mg vial(s) 160 mg vial(s) |
| Kadcyla | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 3 weeks | String (up to 50 characters) |
| Kadcyla | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Perjeta
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|
| Perjeta | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - |
| Perjeta | Oncology | Prescription Option | MedicationRequest.Notes | 840 mg as Initial Dose | Once every 3 weeks | Other |
| Perjeta | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) |
| Perjeta | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Perjeta | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number |
| Perjeta | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 420 mg vial(s) | 420 mg vial(s) | 420 mg vial(s) |
| Perjeta | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once | Once every 3 weeks | String (up to 50 characters) |
| Perjeta | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Phesgo
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|
| Phesgo | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - |
| Phesgo | Oncology | Prescription Option | MedicationRequest.Notes | 1200 mg pertuzumab/600 mg trastuzumab/30,000 units hyaluronidase | 600 mg pertuzumab/600 mg trastuzumab/20,000 units hyaluronidase | Other |
| Phesgo | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 1200 | 600 | any number (up to 5 characters) |
| Phesgo | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Phesgo | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number |
| Phesgo | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 1200mg 1800mg | 1200mg 1800mg | 1200mg 1800mg |
| Phesgo | Oncology | 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) |
| Phesgo | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Polivy
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Polivy | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Polivy | Oncology | Prescription Option | MedicationRequest.Notes | Once Every 21 Days | Other |
| Polivy | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) |
| Polivy | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Polivy | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Polivy | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 30 mg vial(s) 140 mg vial(s) | 30 mg vial(s) 140 mg vial(s) |
| Polivy | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 21 weeks | String (up to 50 characters) |
| Polivy | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Rituxan Hycela
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|---|---|
| Rituxan Hycela | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - | - | - |
| Rituxan Hycela | Oncology | Prescription Option | MedicationRequest.Notes | Every 2 Months | Every 21 Days | Every 28 Days | Other | Weekly |
| Rituxan Hycela | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) |
| Rituxan Hycela | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg |
| Rituxan Hycela | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number | Any number | Any number |
| Rituxan Hycela | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 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) |
| Rituxan Hycela | Oncology | 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 |
| Rituxan Hycela | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Rituxan for Oncology
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Rituxan Oncology | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Rituxan Oncology | Oncology | Prescription Option | MedicationRequest.Notes | Once a Week for 3 weeks | Other |
| Rituxan Oncology | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) |
| Rituxan Oncology | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Rituxan Oncology | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Rituxan Oncology | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 100 mg vial(s) 500 mg vial(s) | 100 mg vial(s) 500 mg vial(s) |
| Rituxan Oncology | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once a week | String (up to 50 characters) |
| Rituxan Oncology | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Rozlytrek
| Product | Therapeutic Area | 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 Starter SR (Option 1) | Prescription Values for Starter SR (Option 2) |
|---|---|---|---|---|---|---|---|
| Rozlytrek | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | Starter | Starter |
| Rozlytrek | Oncology | Prescription Option | MedicationRequest.Notes | 600 mg once daily | Other | 600 mg once daily | Other |
| Rozlytrek | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 600 | any number (up to 5 characters) | 600 | any number (up to 5 characters) |
| Rozlytrek | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg |
| Rozlytrek | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | any number (up to 5 characters) | 1 | 1 |
| Rozlytrek | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Months(s) | Months(s) | Months(s) | Months(s) |
| Rozlytrek | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | QD | String (up to 50 characters) | QD | String (up to 50 characters) |
| Rozlytrek | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 1 | 0 - 1 |
Prescription options for Tecentriq
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Tecentriq | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - |
| Tecentriq | Oncology | Prescription Option | MedicationRequest.Notes | Once every 3 weeks | Other |
| Tecentriq | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) |
| Tecentriq | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Tecentriq | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Tecentriq | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 840 mg vial(s) 1200 mg vial(s) | 840 mg vial(s) 1200 mg vial(s) |
| Tecentriq | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 3 weeks | String (up to 50 characters) |
| Tecentriq | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Xeloda -- ### MAPPING TBC
Note: For Xeloda, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | 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 1) | Prescription Values for Patient Foundation SR OR BIPA SR (Option 2) |
|---|---|---|---|---|---|---|---|
| Xeloda | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | Standard | Standard | Other | Other |
| Xeloda | Oncology | Prescription Option | MedicationRequest.Notes | 150 mg | 500 mg | 150 mg | 500 mg |
| Xeloda | Oncology | # of Tablets | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | - | - |
| Xeloda | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 150 | 500 | 150 | 500 |
| Xeloda | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg |
| Xeloda | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 30 | 1 - 30 | - | - |
| Xeloda | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Day(s) | Day(s) | - | - |
| Xeloda | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | 1 - 5 | 1 - 5 | - | - |
| Xeloda | Oncology | SIG | MedicationRequest.dosageInstruction.text | - | - | String (up to 50 characters) | String (up to 150 characters) |
| Xeloda | Oncology | Days off | MedicationRequest.dispenseRequest.dispenseInterval | 1 - 30 | 1 - 30 | - | - |
| Xeloda | Oncology | # tablets per cycle | MedicationRequest.dispenseRequest.quantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) |
| Xeloda | Oncology | # cycles per fill | MedicationRequest.dispenseRequest.quantity.unit | 1 - 12 | 1 - 12 | 1 - 12 | 1 - 12 |
| Xeloda | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Venclexta - Patient Foundation or BIPA SR
Note: For Venclexta, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | 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 Values for Patient Foundation SR |
|---|---|---|---|---|---|---|---|---|---|
| Venclexta | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | CLL/SLL (Maint) | AML (Maint) | Other Dosing (Maint) | AML (Ramp-up) | Other Dosing (Ramp-up) | CLL/SLL (Start) |
| Venclexta | Oncology | Prescription Option | MedicationRequest.Notes | Maintenance | Maintenance | Maintenance | Ramp-up Dosing | Ramp-up Dosing | Starting Pack |
| Venclexta | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) | Dosage (Day:1) Dosage (Day:2) Dosage (Day:3) String (up to 5 characters for each Day Dosage) | any number (up to 5 characters) | - |
| Venclexta | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg | - |
| Venclexta | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 | 1 | 1 | 3 | 1 | 1 |
| Venclexta | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Month(s) | Month(s) | Month(s)) | Day(s) | Month(s) | Month(s) |
| Venclexta | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Daily | Daily | Daily | Daily | - | - |
| Venclexta | Oncology | SIG | MedicationRequest.dosageInstruction.text | - | - | - | - | String (up to 150 characters) | - |
| Venclexta | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 1 | 0 - 1 | 0 - 1 | 0 | 0 - 1 | 0 |
Prescription options for Venclexta - Starter SR
Note: For Venclexta, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | 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 Values for Patient Foundation SR (OPTION 3) |
|---|---|---|---|---|---|---|---|---|---|
| Venclexta | Oncology | 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) |
| Venclexta | Oncology | Prescription Option | MedicationRequest.Notes | Maintenance | Maintenance | Maintenance | Ramp-up Dosing | Ramp-up Dosing | Starting Pack |
| Venclexta | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) | Dosage (Day:1) Dosage (Day:2) Dosage (Day:3) String (up to 5 characters for each Day Dosage) | any number (up to 5 characters) | - |
| Venclexta | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg | - |
| Venclexta | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 | 1 | 1 | 3 | 1 | 1 |
| Venclexta | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Month(s) | Month(s) | Month(s)) | Day(s) | Month(s) | Month(s) |
| Venclexta | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Daily | Daily | Daily | Daily | - | - |
| Venclexta | Oncology | SIG | MedicationRequest.dosageInstruction.text | - | - | - | - | String (up to 150 characters) | - |
| Venclexta | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 1 | 0 - 1 | 0 - 1 | 0 | 0 - 1 | 0 |
Prescription options for Zelboraf
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|
| Zelboraf | Oncology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - |
| Zelboraf | Oncology | Prescription Option | MedicationRequest.Notes | 960 mg Twice a day | 960 mg twice daily for 21, 720 mg twice daily thereafter | Other |
| Zelboraf | Oncology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 960 | 960 | any number (up to 5 characters) |
| Zelboraf | Oncology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Zelboraf | Oncology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | 1 - 3 | 1 - 3 |
| Zelboraf | Oncology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Month(s) | Month(s) | Month(s) |
| Zelboraf | Oncology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | BID | BID | String (up to 50 characters) |
| Zelboraf | Oncology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Lucentis
Note: For Lucentis, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Lucentis | Ophthalmology | 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 |
| Lucentis | Ophthalmology | Prescription Option | MedicationRequest.Notes | 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 |
| Lucentis | Ophthalmology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 0.3 | 0.3 | 0.3 | 0.3 | 0.5 | 0.5 | 0.5 | 0.5 |
| Lucentis | Ophthalmology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg | mg | mg | mg |
| Lucentis | Ophthalmology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number | Any number | Any number | Any number | Any number | Any number |
| Lucentis | Ophthalmology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) | 0.3 mg prefilled syringe(s) OR 0.5 mg prefilled syringe(s) |
| Lucentis | Ophthalmology | 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) |
| Lucentis | Ophthalmology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Susvimo
Note: For Susvimo, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|
| Susvimo | Ophthalmology | Prescription Type | MedicationRequest.courseOfTherapyType.text | Implant Kit | Refill Kit |
| Susvimo | Ophthalmology | Prescription Option | MedicationRequest.Notes | Once every 24 weeks | Other |
| Susvimo | Ophthalmology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 2 | 2 |
| Susvimo | Ophthalmology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg |
| Susvimo | Ophthalmology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number |
| Susvimo | Ophthalmology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Ocular Implant with Insertion Tool OR 2 mg (+ initial fill needle) OR 2 mg (+ refill needle) | Ocular Implant with Insertion Tool OR 2 mg (+ initial fill needle) OR 2 mg (+ refill needle) |
| Susvimo | Ophthalmology | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Once every 24 weeks | String (up to 50 characters) |
| Susvimo | Ophthalmology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 |
Prescription options for Ocrevus
Note: For Ocrevus, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for BIPA SR | Prescription Values for Patient Foundation (OPTION 1) | Prescription Values for Patient Foundation (OPTION 2) | Prescription Values for BIPA SR | Prescription Values for Patient Foundation (OPTION 1) | Prescription Values for Patient Foundation (OPTION 2) |
|---|---|---|---|---|---|---|---|---|---|
| Ocrevus | MS/NMO | Prescription Type | MedicationRequest.courseOfTherapyType.text | Initial Dose | Initial Dose | Initial Dose | Subsequent Dose | Subsequent Dose | Subsequent Dose |
| Ocrevus | MS/NMO | Prescription Option | MedicationRequest.Notes | Initial Dose | Day 1 & Day 15 | Other | Subsequent Dose | Every 6 months | Other |
| Ocrevus | MS/NMO | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | - | any number (up to 5 characters) | any number(up to 5 characters) | - | any number(up to 5 characters) | any number(up to 5 characters) |
| Ocrevus | MS/NMO | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | - | mg | mg | - | mg | mg |
| Ocrevus | MS/NMO | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 | Any number | Any number | 2 | Any number | Any number |
| Ocrevus | MS/NMO | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 300 mg vial(s) | 300 mg vial(s) | 300 mg vial(s) | 300 mg vial(s) | 300 mg vial(s) | 300 mg vial(s) |
| Ocrevus | MS/NMO | 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) |
| Ocrevus | MS/NMO | 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) |
| Ocrevus | MS/NMO | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 1 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Enspryng
Note: For Enspryng, up to 2 prescriptions can be submitted; maximum of 1 per Prescription Type
| Product | Therapeutic Area | Field Name | Resource-ElementID | Prescription Values for BIPA SR | Prescription Values for BIPA SR | Prescription Values for Patient Foundation | Prescription Values for Patient Foundation SR (OPTION 1) | Prescription Values for Patient Foundation SR (OPTION 2) |
|---|---|---|---|---|---|---|---|---|
| Enspryng | MS/NMO | Prescription Type | MedicationRequest.courseOfTherapyType.text | Loading Dose | Maintenance Dose | Loading Dose | Maintenance Dose | Maintenance Dose |
| Enspryng | MS/NMO | Prescription Option | MedicationRequest.Notes | Inject 120 mg | Inject 120 mg | Inject 120 mg | Inject 120 mg | Other |
| Enspryng | MS/NMO | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 120 | 120 | 120 | 120 | 120 |
| Enspryng | MS/NMO | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg |
| Enspryng | MS/NMO | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 3 | 1 | 3 | 1 | TBC how to handle 2 dispense quantity values |
| Enspryng | MS/NMO | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Week(s) | Month(s) | Week(s) | Month(s) | Month(s) |
| Enspryng | MS/NMO | Frequency of administration | MedicationRequest.dosageInstruction.Timing OR MedicationRequest.dosageInstruction.PatientInstructions | Weeks 0, 2, 4 | Every 4 Weeks | Weeks 0, 2, 4 | Every 4 Weeks | - |
| Enspryng | MS/NMO | 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) |
| Enspryng | MS/NMO | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 | any number (up to 3 characters) | 0 | any number (up to 3 characters) | 0 - 12 |
Prescription options for Actemra Intravenous
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|
| Actemra Intravenous | Rheumatology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - |
| Actemra Intravenous | Rheumatology | Prescription Option | MedicationRequest.Notes | Once every 2 weeks | Once every 4 weeks | Other |
| Actemra Intravenous | Rheumatology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) |
| Actemra Intravenous | Rheumatology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Actemra Intravenous | Rheumatology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | any number (up to 5 characters) |
| Actemra Intravenous | Rheumatology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 80 mg vial(s) OR 200 mg vial(s} OR 400 mg vial(s) | 80 mg vial(s) OR 200 mg vial(s) OR 400 mg vial(s) | 80 mg vial(s) OR 200 mg vial(s) OR 400 mg vial(s) |
| Actemra Intravenous | Rheumatology | Frequency of administration | MedicationRequest.dosageInstruction.TimingORMedicationRequest.dosageInstruction.PatientInstructions | Once every 2 weeks | Once every 4 weeks | String (up to 50 characters) |
| Actemra Intravenous | Rheumatology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Actemra Subcutaneous
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|---|---|
| Actemra Subcutaneous | Rheumatology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - | Starter | Starter |
| Actemra Subcutaneous | Rheumatology | Prescription Option | MedicationRequest.Notes | ACTPen 162mg | Inject 162mg | Other | ACTPen 162mg | Prefilled Syringe |
| Actemra Subcutaneous | Rheumatology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | 162 | 162 | 162 | 162 | 162 |
| Actemra Subcutaneous | Rheumatology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg | mg | mg |
| Actemra Subcutaneous | Rheumatology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | 1 - 3 | 1 - 3 | any number (up to 5 characters) | 15 | 15 |
| Actemra Subcutaneous | Rheumatology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | Months(s) | Months(s) | Week(s) OR Month(s) | Day(s) | Day(s) |
| Actemra Subcutaneous | Rheumatology | 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) | Once every 2 weeks OR Once a week | Once every 2 weeks OR Once a week |
| Actemra Subcutaneous | Rheumatology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 | 0 - 12 |
Prescription options for Rituxan for Immunology
| Product | Therapeutic Area | 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) |
|---|---|---|---|---|---|---|
| Rituxan for Immunology | Rheumatology | Prescription Type | MedicationRequest.courseOfTherapyType.text | - | - | - |
| Rituxan for Immunology | Rheumatology | Prescription Option | MedicationRequest.Notes | Day 1 and Day 15 | Once a Week for 4 week | Other |
| Rituxan for Immunology | Rheumatology | Dosage | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | any number (up to 5 characters) | any number (up to 5 characters) | any number (up to 5 characters) |
| Rituxan for Immunology | Rheumatology | Dosage unit | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | mg | mg | mg |
| Rituxan for Immunology | Rheumatology | Dispense quantity | MedicationRequest.dispenseRequest.expectedSupplyDuration.value | Any number | Any number | Any number |
| Rituxan for Immunology | Rheumatology | Dispense unit | MedicationRequest.dispenseRequest.ExpectedSupplyDuration.unit | 100 mg vial(s) OR 500 mg vial(s) | 100 mg vial(s) OR 500 mg vial(s) | 100 mg vial(s) OR 500 mg vial(s) |
| Rituxan for Immunology | Rheumatology | Frequency of administration | MedicationRequest.dosageInstruction.TimingORMedicationRequest.dosageInstruction.PatientInstructions | Day 1 and Day 15 | Once a week | String (up to 50 characters) |
| Rituxan for Immunology | Rheumatology | Refill(s) | MedicationRequest.dispenseRequest.numbersOfRepeatsAllowed | 0 - 12 | 0 - 12 | 0 - 12 |