Specialty and Infusion 340B Under the Rebate Pilot

More than a retail pharmacy change

It is easy to think of the pilot as a retail pharmacy issue, but HRSA is explicit that it also covers physician- and clinic-administered drugs. Several pilot drugs are oral oncology products, including Imbruvica, Xtandi, Ibrance and Pomalyst, and these often reach patients through specialty pharmacies. The full list is in our 340B rebate pilot drug list.

The data a medical claim needs

Drugs given in a clinic or infusion setting go to Beacon as medical claims, which use different fields from pharmacy claims:

• Date of service, claim number and claim line number
• NDC-11, quantity and unit of measure
• Rendering physician ID and service provider (site of care) ID
• 340B ID, health plan name and health plan ID

Quantity and unit of measure must match Beacon's NDC list. Most plans accept both pharmacy and medical claims, but Pfizer's plan, which covers Ibrance, is pharmacy only.

Each plan handles wasted units differently

HRSA requires every plan to explain how wasted or undispensed units are reported. Amgen, Astellas, Bristol Myers Squibb and Merck want wasted units on a separate medical claim line under the same claim number. AbbVie and AstraZeneca do not expect wastage claims, Boehringer Ingelheim and Pfizer point to returns, and GSK and Teva do not say. Getting this wrong is an easy way to end up with a denial.

Your specialty pharmacy dispenses, you submit

Specialty pharmacies do not submit pilot claims to Beacon. The covered entity does. When a specialty pharmacy dispenses a pilot drug to your patient, your TPA or someone on your team has to get that claim to Beacon, complete and within 45 days. That only works if the specialty pharmacy’s claim data reaches you in the first place.

Where Aventi fits

Aventi focuses on specialty medications and infusion. We bring in specialty pharmacy claims through a gateway with BioPlus, Accredo, Optum and others, and integrate with major EHRs for administered-drug claims. Both pharmacy and medical rebate claims go to Beacon.