REDLINE Contract Pharmacy Registration

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau

OMB No. 0915-0327

340B Contract Pharmacy Registration

	340B ID	Entity Type	Entity Name	Sub Name	Address	City	State	Start Date	Term Date	Edit Date
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	340B ID	Entity Type	Entity Name	Sub Name	Address	City	State	Start Date	Term Date	Edit Date


	340B ID	Entity Type	Entity Name	Sub Name	Address	City	State	Start Date	Term Date	Edit Date


Pharmacy Name	Pharmacy Address	Pharmacy Representative	Medicaid	Remove Registration?
			*	Remove

March 06, 2015 1:16 PM ET [email protected] | 1-888-340-2787 OMB Number: 0915-0327, Expiration: 09/30/2018

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* Text will vary based on the selection on the prior screen:

Dispenses 340B drugs to Medicaid patients and subsequently bills Medicaid for those transactions

-- OR --

The contract pharmacy will not dispense 340B drugs to Medicaid patients, nor subsequently bill Medicaid for those transactions.

340B ID: DSH999999 XYZ MEDICAL CENTER

A contract pharmacy registration has been submitted regarding DSH999999 – XYZ MEDICAL CENTER, at 1 HOSPITAL DR, ANYWHERE, AR 99999

Contract pharmacy registrations are available to be approved or rejected for 15 calendar days after submission. On the 16th day, any contract pharmacy registrations that have not been approved or rejected will expire.

You may approve or reject multiple pharmacies at once, but approvals and rejections must be done separately. Click the checkboxes next to the pharmacies you wish to approve or reject, then review and agree to the certification statement, then click the appropriate button below. If necessary, repeat the above steps to approve or reject the remaining registrations.

NOTE: Approving or rejecting a registration is final – your selection cannot be changed.

Requestor Details

Request Number: ^CP999999

_Name: John Smith

_Title: Pharmacy Director

_{Organization:} XYZ Medical Center

Phone: ^{999­999­9999 Ext:}

_Email: [email protected]

Remarks:

* Text will vary based on selection at registration Dispenses 340B drugs to Medicaid patients and subsequently bills Medicaid for those transactions

-- OR --

The contract pharmacy will not dispense 340B drugs to Medicaid patients, nor subsequently bill Medicaid for those transactions.

Select All	Pharmacy Name	Pharmacy Address	CP Representative	Medicaid	Request Status
	TEST PHARMACY	1 MAIN STREET ANYWHERE, AR	Test Representative Test 999­999­9999 [email protected]	[see note above]	Submitted

By checking this box, I represent and confirm that I am fully authorized to bind the Covered Entity and the Pharmacy listed, and certify that the contents of any statement made or reflected in this document are truthful and accurate. The Covered Entity and the Pharmacy will comply with all of the requirements and restrictions of Section 340B of the Public Health Service Act and any accompanying regulations or guidelines, including, but not limited to, the prohibitions on duplicate discounts/rebates, and drug diversion. The Covered Entity and the Pharmacy agree to be in compliance with the provisions of the Contract Pharmacy Services Guidelines as set forth in the Federal Register, at 75 Fed. Reg. 10272 (March 5, 2010), which can be found at http://www.gpo.gov/fdsys/pkg/FR­ 2010­03­05/pdf/2010­4755.pdf (http://www.gpo.gov/fdsys/pkg/FR­2010­03­05/pdf/2010­4755.pdf). The authorizing official certifies on behalf of the covered entity that the contract pharmacy arrangement will be performed in accordance with OPA requirements and guidelines including, but not limited to, that the Covered Entity obtains sufficient information from the contractor to ensure compliance with applicable policy and legal requirements, and the Covered entity has utilized an appropriate methodology to ensure compliance (e.g., through an independent audit or other mechanism). The Covered Entity has, and continues to bear, full responsibility and accountability for compliance with all 340B requirements, including but not limited to any 340B violations by the Contract Pharmacy. The Covered Entity agrees to notify the Office of Pharmacy Affairs, in writing, of any material changes in the contract arrangement and/or material breach by the covered entity of any of the foregoing.

For any contract pharmacy arrangements where ‘Dispenses 340B drugs to Medicaid fee-for-service patients and subsequently bills Medicaid fee-for-service for those transactions' is indicated above, the Entity further attests that the contract pharmacy dispenses 340B drugs to Medicaid fee-for-service patients through an established arrangement of the covered entity, the contract pharmacy and the State Medicaid agency that has been reported by the covered entity to HRSA/OPA. All covered entities should notify HRSA prior to any change in Medicaid billing status. For more information, please visit the HRSA website at http://www.hrsa.gov/opa.

Approve

Click the button to approve this contract pharmacy registration.

Reject

Click the button button to reject this contract pharmacy registration.

For additional assistance regarding 340B contract pharmacy, please contact the 340B Prime Vendor Program at 1­888­340­2787 or by email at [email protected]. Please reference your 340B ID number in the communication.

You may also contact OPA at:

Office of Pharmacy Affairs Mail Stop 8W05A

5600 Fishers Lane

Rockville, MD 20857

Email: [email protected]

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0327. Public reporting burden for this collection of information is estimated to average 1 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.