The 340B program is designed to allow eligible Covered Entities to stretch scarce health care dollars to provide services to the communities they serve and support the uninsured and underinsured patients with options that help them afford their prescription medications.
Review Prescriptions and Capture Rate
Most participating Covered Entities might not be taking full advantage of the 340B program. A quick review of the total annual prescriptions written by providers compared to the total prescriptions captured in your 340B program can give you an idea of how well your program is optimized. This can be done by routinely reviewing key reports from your e-prescribe program and should always be done in collaboration with your 340B TPA to ensure that capture logic is taken into consideration.
Close attention to the pharmacies in your network and the capture model used can provide valuable insight when evaluating your program. Certain chain pharmacies subscribe to the “all claims” capture model, which may increase your overall capture rate but can harm the profitability of your program. It may be beneficial to review the chain pharmacies in your network that subscribe to the “all claims” capture model separately as this can determine their value vs. chain pharmacies using other models, like “brand only” and “profit only.” When reviewing your annual capture rate, pay attention to all pharmacies where prescriptions are being filled by reviewing e-prescribe data and contract pharmacy performance. Patients can change the pharmacies where they go to fill their prescriptions over time. This review can identify additional pharmacies that should be contracted and added to your network.
Tap into Specialty Pharmacy
It's common to overlook capturing prescriptions written by specialists where your providers have referred patients for specialized attention. These referral providers are usually endocrinologists, dermatologists, rheumatologists, gastroenterologists, and others who treat specific disease states.
Since the prescriptions written by these referral providers can typically be higher-cost specialty medications, capturing these in your 340B program can add significant additional savings. Your policies and procedures should indicate that your providers are to document all referrals in the patient’s EMR record and ideally, all specialists should be sending a follow-up letter back to the referring provider. From this data and via detailed reports, you can identify which specialty pharmacies your patients are using to fill these prescriptions. Once identified, you can contract with each specialty pharmacy to be included in your 340B network.
A key part of capturing these referral prescriptions is to understand how your TPA’s technology works. Additional logic and functionality are required to bring these referral prescriptions into the technology. Most specialty pharmacies don’t use switch data but rather have a direct data feed to TPAs. Thus, more than a data pull from the specialty pharmacies needs to be done to effectively capture all the appropriate specialty claims. TPAs that capture specialty claims effectively have sophisticated referral claims technology, plus additional services that monitor capture logic, as these may need to be adjusted from time to time. It may be beneficial to allocate resources, additional TPA services, or an experienced 340B consultant to monitor referral capture — it can pay dividends for growing your 340B program.