_______________________________________________________________________________________ Table 1: Entity Data, Contract Pharmacy Data 340B ID HIN (if Wholesaler Entity Address 1 Address City Zip HRSA HRSA known) or Name, 2 Start Term. Distributor Subdivision Date Date Name and Name Account Number Ship To HIN Wholesaler Wholesaler Address 1 Address City State Zip Contract Contract (if or known) or Account 2 Start Term. Contract Distributor Number Date Date Pharmacy Name Name Table 2: [Manufacturer] Repayment/Credit Summary 11 digit Pkg Product Number [Entity] WAC or Contract Invoice Invoice Chargeback Wholesaler Total NDC Units Shipped of units 340B Contract Used to Date Number Memo Refund/Credit to: (please Acquisition Price per Purchase Number (as agreed (Name, report at Costs per unit (Include upon between address) the NDC unit Represented Contract the CE and level) Represented by NDC Number) manufacturer) by NDC This tool is written to align with Health Resources and Services Administration (HRSA) policy, and is provided only as an example for the purpose of encouraging 340B Program integrity. This information has not been endorsed by HRSA and is not dispositive in determining compliance with or participatory status in the 340B Drug Pricing Program. 340B stakeholders are ultimately responsible for 340B Program compliance and compliance with all other applicable laws and regulations. Apexus encourages all stakeholders to include legal counsel as part of their program integrity efforts. © 2018 Apexus. Permission is granted to use, copy, and distribute this work solely for 340B covered entities and Medicaid agencies.
_______________________________________________________________________________________ Table 1: Entity Data, Contract Pharmacy Data 340B ID HIN (if known) Wholesaler or Distributor Name and Account Number Entity Name, Subdivision Name Address 1 Address 2 City Zip HRSA Start Date HRSA Term. Date Ship To or Contract Pharmacy Name HIN (if known) Wholesaler or Distributor Name Wholesaler Account Number Address 1 Address 2 City State Zip Contract Start Date Contract Term. Date Table 2: [Manufacturer] Repayment/Credit Summary 11 digit NDC Pkg Units Product Shipped to: (Name, address) Number of units (please report at the NDC level) [Entity] 340B Acquisition Costs per unit Represented by NDC WAC or Contract Price per unit Represented by NDC Contract Used to Purchase (Include Contract Number) Invoice Date Invoice Number Chargeback Memo Number Wholesaler Total Refund/Credit (as agreed upon between the CE and manufacturer) This tool is written to align with Health Resources and Services Administration (HRSA) policy, and is provided only as an example for the purpose of encouraging 340B Program integrity. This information has not been endorsed by HRSA and is not dispositive in determining compliance with or participatory status in the 340B Drug Pricing Program. 340B stakeholders are ultimately responsible for 340B Program compliance and compliance with all other applicable laws and regulations. Apexus encourages all stakeholders to include legal counsel as part of their program integrity efforts. © 2018 Apexus. Permission is granted to use, copy, and distribute this work solely for 340B covered entities and Medicaid agencies.
self-disclosure-to-hrsa-and-manufacturer-template.docx