Your HTC 340B Program is Out of Network, Now What?

Know your program Understand how your program functions Are you part of a larger institution? Who are the internal key personnel involved in the oversight and decision making for the HTC 340B program? Who manages and negotiates contracts related the HTC 340B program? What data do you track to support quality outcomes and cost savings? www.hemoalliance.org info@hemoalliance.org

Engage the Patient Ensure the patient wants to utilize your HTC 340B program and that the patient choice and HIPAA privacy notices are current and signed. Obtain current insurance card from patient. Obtain insurance plan documentation from patient if possible. Determine if plan is traditional insurance product, government program, or self-funded employer plan. *You must determine who the ultimate payer is to engage in appropriate outreach efforts* www.hemoalliance.org info@hemoalliance.org

Contact the Insurer Perform a benefit inquiry for the patient's policy coverage. *record date, time and person contacted* Is blood clotting factor covered under the medical or pharmacy benefit or if permissible to be covered under either? If pharmacy benefit, obtain a list of all in network pharmacy providers. Who is your competition? Obtain information on patient responsibility for out of pocket costs and prior authorization requirements for clotting factor. Inquiry into insurer’s policy or state law regarding any willing provider clause. *if plan is employer self funded state law may not apply* www.hemoalliance.org info@hemoalliance.org

HTC Value Understand your data and the value proposition you are offering compared to your competitors. Assume competitor's commercial acquisition price equals the published PHS price times 1.171(17.1%) plus $.04 to $.08 mark up Create your HTC case studies showing costs savings through better disease and assay management in conjunction with discounted pricing Utilize the Hemophilia Alliance insurance toolkit to customize your presentation for the target audience you are engaging. www.hemoalliance.org info@hemoalliance.org

Ask for support Ask for support from The Hemophilia Alliance team Seek the support of your institution’s contracting team Can you supply factor under your institution’s existing contracts? Leverage the institution’s contractual relationship with the insurer to gain in network access or to negotiate a single case rate agreement Ask for support from The Hemophilia Alliance team www.hemoalliance.org info@hemoalliance.org

Now that you have the knowledge Engage with patient to advocate and educate insurer, PBM or employer. The patient should do the first outreach to their HR department. The patient should share why there is a need for specific services such as stat delivery for emergency, nursing support, etc. Present the value proposition Stay engaged and maintain continuing communication. www.hemoalliance.org info@hemoalliance.org