02/14/2023

Health Alliance Plan

Health Alliance Plan Managed Care Committee Member

April Danish, CHONC - Newland Medical Associates

CMS Ruling on Payment Rates for Drugs Acquired Through 340B Program
On December 20, 2022, the Centers for Medicare & Medicaid Services (CMS) issued an update to
Medicare Advantage organizations, Prescription Drug Plans, and others with respect to Medicare
Hospital Outpatient Prospective Payment System (OPPS) payment rates for drugs acquired
through the 340B program. In that notice, CMS stated, among other things, that:

• CMS cannot apply the Average Sales Price (ASP) minus 22.5% drug payment rate for
  340B-acquired drugs for the remainder of the year, which had been the previous policy in
  effect beginning CY 2018.
• CMS will revert to paying the default rate (generally ASP plus 6%) under Medicare statute
  for 340B-acquired drugs and will reprocess claims paid on or after September 28, 2022,
  using the default rate.
• CMS will address 340B drug payments from CYs 2018-2022 in future rulemaking.

For details, please see the CMS notice.

Next Steps
In compliance with CMS, HAP will be reprocessing affected claims that were paid on or after
September 28, 2022. You do not need to resubmit these claims.

Our systems have been updated to reflect a general payment rate of ASP plus 6% for drugs and
biologicals acquired through the 340B Program that were paid on or after September 28, 2022.