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New Requirements by Anthem for 340B Participants

Attention 340B covered entities participating with Anthem Blue Cross and Blue Shield: Effective April 1, 2019, Anthem requires that a “JG,” “TB,” or another relevant modifier be added to claims involving 340B eligible outpatient drugs under the Medicare Outpatient Prospective Payment System (OPPS).

This decision by Anthem resembles the January 1, 2018 decision by the Centers for Medicare and Medicaid Services (CMS) to reduce the Medicare Part B allowed reimbursement rate for 340B drugs from ASP plus 6 percent to ASP minus 22.5 percent. CMS simultaneously increased the conversion factor for all OPPS non-drug items and services by approximately 3.2%.

It may be prudent to reach out to Anthem for clarity on this issue. A recent federal court ruling in Washington reversed the enormous cuts to the Medicare outpatient drug payments implemented by CMS. A federal judge ruled in late December 2018 that CMS and HHS exceeded their authority by cutting 340B reimbursement by approximately 28.5%. While this ruling appears to be a win for the hospitals affected by the payments cuts, it is not certain how this issue will be settled. Additionally, there has been no guidance by Anthem as to how this ruling affects their position.

Anthem advises that these facilities are excluded from this billing requirement:

  • Sole Community Hospitals (SCHs)
  • Children’s Hospitals
  • PPO-Exempt Cancer Hospitals
  • Critical Access Hospitals (CAHs)
  • Drugs administered or dispensed in non-excepted Hospital off-campus outpatient departments (HOPDs)

Blue & Co. will continue to monitor the situation and update clients as more information becomes available. If you have any questions, please contact one of our 340B Apexus Certified Experts:

Jason Prokopik, Pharmacy Manager
jprokopik@blueandco.com
317-713-7916

 

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