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

Express Scripts’ New 340B Claims ID Requirement Has Covered Entities Worried

Pharmacy benefit manager Express Scripts late yesterday began notifying 340B covered entities by email that, effective March 1, it “will require a new identification method for submitting and identifying 340B eligible claims.”

A health system 340B program manager said this morning, “If this is not reversed, it could be the biggest attack on contract pharmacy so far.” Another 340B stakeholder we asked to grade the significance of the development on a scale of 1 to 10 rated it an 8.

Starting Monday, Express Scripts will require pharmacies in its network that bill claims using 340B-purchased stock, and that determine post-adjudication that a previously submitted claim is 340B-eligible, to identify the claim to Express Scripts within 10 business days. Covered entities expressed concern to 340B Report about whether they would continue to be able, under Express Scripts’ new requirements, to access 340B pricing on drugs dispensed by contract pharmacies using a replenishment model.

A 340B pharmacy consultant to covered entities said it appears that Express Scripts is requiring entities to submit their 340B acquisition cost in addition to electronically submitting a specified claims clarification code value. The consultant questioned whether covered entities possessed the legal right to share that cost information with the PBM.

Other 340B provider stakeholders questioned whether covered entities and their 340B third party administrators (TPA) could reconfigure pharmacy inventory management software in time to meet the March 1 deadline. Some said they doubted whether chain drugstores that serve as 340B contract pharmacies will agree to add the claims modifiers that Express Scripts now requires. Others note that Express Scripts has not indicated what they intend to do with the information they collect; for example, whether they would sell it to manufacturers, or use it in connection with negotiating commercial rebates with manufacturers.

This is a developing story. We will reach out to Express Scripts for comment in a follow-up article.

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