Table 2: 340B ID Site-Specific Drug Universe From Table 1, list the 340B ID of the entity and any child sites or associated sites registered in 340B 340B ID# 1: 340B ID # 2: 340B ID # 3: OPAIS in the column heading to the right and document the following: Document the location name. Name Name Name Document the physical address, Address Address Address including suite number of the site Do providers write prescriptions for patient self-administration that Yes or No Yes or No Yes or No are filled with 340B drugs? Does this location administer drugs as part of outpatient Yes or No Yes or No Yes or No encounters? 4a. Document type(s) of drug 340B 340B 340B inventory in this site. WAC WAC WAC GPO GPO GPO 4b. Document all purchasing 340B Account# accounts used (wholesaler/ 340B Account# with__ 340B Account# with__ with__ manufacturer). Include name and WAC Account# with__ WAC Account# with__ WAC Account# account number for each GPO Account# with __ GPO Account# with __ with__ inventory type used. GPO Account# with __ 4c. Document inventory management Physical Physical Physical method used. Virtual Virtual Virtual Both Physical & Both Physical & Virtual Both Physical & Virtual Virtual 4d. Document automated dispensing Device Name Device Name Device Name devices used. 4e. Document the inventory tracking Vendor software Vendor software Vendor software system used. Specify software Paper tracking log Paper tracking log Paper tracking log name, if applicable. Electronic tracking Electronic tracking log Electronic tracking log log Does this site carve-in Medicaid Yes or No Yes or No Yes or No and bill 340B drugs to Medicaid? 5a. Document all Medicaid and/or NPI numbers used to bill 340B drugs to Medicaid. Billing numbers used Billing numbers used Billing numbers used Note: Billing numbers used to carve-in Medicaid must be listed in the Medicaid Exclusion File. Document all Medicaid and/or NPI numbers used to bill Billing numbers used Billing numbers used Billing numbers used drugs to Medicaid. 340B ID Specific Drug Operations Environment completed by: (name, title, and date)
Table 2: 340B ID Site-Specific Drug Universe From Table 1, list the 340B ID of the entity and any child sites or associated sites registered in 340B OPAIS in the column heading to the right and document the following: 340B ID# 1: 340B ID # 2: 340B ID # 3: Document the location name. Name Name Name Document the physical address, including suite number of the site Address Address Address Do providers write prescriptions for patient self-administration that are filled with 340B drugs? Yes or No Yes or No Yes or No Does this location administer drugs as part of outpatient encounters? Yes or No Yes or No Yes or No 4a. Document type(s) of drug inventory in this site. 340B WAC GPO 340B WAC GPO 340B WAC GPO 4b. Document all purchasing accounts used (wholesaler/ manufacturer). Include name and account number for each inventory type used. 340B Account# with__ WAC Account# with__ GPO Account# with __ 340B Account# with__ WAC Account# with__ GPO Account# with __ 340B Account# with__ WAC Account# with__ GPO Account# with __ 4c. Document inventory management method used. Physical Virtual Both Physical & Virtual Physical Virtual Both Physical & Virtual Physical Virtual Both Physical & Virtual 4d. Document automated dispensing devices used. Device Name Device Name Device Name 4e. Document the inventory tracking system used. Specify software name, if applicable. Vendor software Paper tracking log Electronic tracking log Vendor software Paper tracking log Electronic tracking log Vendor software Paper tracking log Electronic tracking log Does this site carve-in Medicaid and bill 340B drugs to Medicaid? Yes or No Yes or No Yes or No 5a. Document all Medicaid and/or NPI numbers used to bill 340B drugs to Medicaid. Note: Billing numbers used to carve-in Medicaid must be listed in the Medicaid Exclusion File. Billing numbers used Billing numbers used Billing numbers used Document all Medicaid and/or NPI numbers used to bill drugs to Medicaid. Billing numbers used Billing numbers used Billing numbers used 340B ID Specific Drug Operations Environment completed by: (name, title, and date)
340B-universe-mapping-template.docx