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340B Provider and Claim Submission Requirements

June 30, 2023

WellCare of North Carolina would like to reiterate the 340B provider and claim submission requirements for both the outpatient pharmacy and Physician’s Drug Program (PDP). Providers are required by NC Medicaid to comply with all requirements of their clinical coverage policies for submission of 340B claims for reimbursement. It has come to WellCare's attention that some of these requirements are not being followed - in particular, that the billed charges for 340B medications be the provider's acquisition cost of the drug. The exception for hemophilia drugs is detailed below.

Physician’s Drug Program (PDP) - Clinical Coverage Policy No. 1B

  • The PDP reimburses for drugs billed to Medicaid and NCHC by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA).
  • Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the 'UD' modifier on the drug detail.
  • Providers billing for a 340B drug shall bill the cost that is reflective of their acquisition cost.

Outpatient Pharmacy - Clinical Coverage Policy No. 9 (Updated July 15, 2019)

  • 340B providers must be listed on the HRSA website.
  • 340B providers must submit POS claims with an '8' in the basis of cost determination field (NCPDP D.0 field 423-DN) AND a '20' in the submission clarification field (NCPDP D.0 field 420-DK) to indicate they are dispensing a 340B product. This will eliminate duplicate discounts as the claims will be pulled from rebate collections.
  • 340B providers must submit the actual purchased drug price in the usual and customary charge field.
  • Providers who maintain two separate inventories - one for eligible 340B prescriptions and a purchased inventory for non-340B prescriptions - may not dispense a 340B program purchased drug and bill Medicaid or NC Health Choice the calculated Medicaid price for non-qualified 340B prescriptions.
  • Hemophilia drugs
    • 340B providers may submit the state upper limit established for a 340B purchasedhemophilia drug.

The referenced clinical coverage policies can be found at: