The 340B Coalition told Express Scripts that covered entities cannot comply with its new 340B claims submission and identification requirement absent "a massive investment of financial and human resources." | Shutterstock

340B Groups Ask Express Scripts to Drop Claims Submission and ID Requirement

Groups representing 340B health care providers have asked pharmacy benefit manager Express Scripts (ESI) to stop making 340B providers and their contract pharmacies retrospectively submit and flag 340B claims in a way that has never been done before, and that cannot be done “without a massive investment of financial and human resources.”

The 13 provider associations in the 340B Coalition, in a March 26 letter, told ESI that entities and contract pharmacies “currently lack the systems and processes” to use electronic prescription claims transaction N1 to resubmit previously adjudicated claims that are later determined to be 340B-eligible.

“No payer has ever required use of the N1 for 340B claims in the 10 years since it was first authorized,” the coalition told the PBM, “and it would require great time and expense to attempt to operationalize that policy, as it would require manually updating millions of claims.”

Entities fear that their contract pharmacies, unable to comply with ESI’s requirement and unwilling to risk upsetting their non-340B business relationships with the PBM, will decline to fill prescriptions reimbursed through ESI with 340B drugs.

“Losing access to 340B discounts for Express Scripts beneficiaries would erode the vital 340B financial benefit that entities rely upon to carry out their safety-net missions,” 340B Coalition member groups said. “Given Express Scripts’ large national market share and large presence in some local markets, such a loss would be financially devastating for many affected covered entities and their patients.”

“There is nothing in the 340B statute permitting payers to establish billing requirements for 340B drugs that could effectively cut off covered entities’ access to the program,” the coalition said.

ESI’s 340B claims submission and identification requirement took effect on March 1. The PBM says it alerted entities and contract pharmacies in January about the new need to use the N1 transaction. Entities and say they first learned about it in a Feb. 24 email from ESI—less than a week before the effective date.

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