340B Drug Pricing Program (IB25-27)
Date: 09/23/25
Louisiana Healthcare Connections is sharing with providers a recent bulletin for the 340B Drug Pricing Program (IB25-27).
1 SUMMARY
January 1, 2026, revisions are being made to be in accordance with CMS 2434-F 2024 Final Rule, which directs state Medicaid programs to invoice for rebate on all rebate eligible physician-administered drug claims.
- The overlap of the 340B Drug Pricing Program and the Medicaid Drug Rebate program creates the possibility of duplicate discounts, which are prohibited under federal law.
- States are federally mandated to seek federal drug rebates on managed care Medicaid claims, meaning that the potential for duplicate discounts exists for managed care claims.
- Louisiana uses the Health Resources and Services Administration’s (HRSA) Medicaid Exclusion File (MEF) for both fee-for-service (FFS) and managed care claims in order to prevent duplicate discounts.
- Contract pharmacies are not permitted to bill Medicaid for drugs purchased at 340B pricing. This includes both FFS and managed care.
- Pharmacy claims submitted by pharmacies on the Medicaid Exclusion File (MEF) for hepatitis C virus direct-acting antiviral (DAA) agents utilizing submission clarification codes of 20 and 08 will continue to deny.
- Effective January 1, 2026, pharmacies listed on the HRSA MEF shall include the correct submission clarification codes on 340B claims. Non-340B claims can be processed without submission clarification codes. It is the pharmacies’ responsibility to correctly identify 340B prescriptions. Incorrectly identifying 340B prescriptions can result in duplicate discounts.
- Effective January 1, 2026, Louisiana will seek rebates on a claim-level basis for physicianadministered drug claims, based upon the modifier attached to the claim. It is the covered entity’s responsibility to correctly identify both 340B and non-340B claims. Incorrectly identifying claims can result in duplicate discounts. Refer to section 5.1.1.2.
- Intentionally including an incorrect 340B modifier on a claim is improper Medicaid billing, and is subject to audit.
Additional information on the 340B Drug Pricing Program can be found at http://www.hrsa.gov/opa.
2. MEDICAID EXCLUSION FILE
HRSA communicates carve-in designations to states via the MEF in order to alert states that Medicaid Drug Rebates should not be invoiced on MEF providers’ drug claims.
When a covered entity chooses to carve-in, it must provide HRSA with the National Provider Identification (NPI) and Medicaid provider number for each site that carves in for the purpose of inclusion in the MEF. An entry in the MEF indicates that a covered entity has chosen to carve-in for a single quarter. Louisiana carve-in 340B covered entities shall be fully enrolled in Louisiana Medicaid and must provide HRSA with both the seven-digit Louisiana Medicaid Provider number and the NPI.
A covered entity can change its carve-in or carve-out designation; however, HRSA stipulates that the effective date of any such change will be the first day of a calendar quarter. Status changes for the next calendar quarter must be provided by the 15th day of the month preceding the quarter’s start (March 15, June 15, September 15 and December 15). Changes submitted after this date will not be effective until the start of the second quarter following the change. Because the MEF is produced on the 15th day of the month preceding a quarter’s start, this ensures that an entity’s carve-in or carve-out election is properly reflected on the applicable quarter’s MEF.
Effective January 1, 2026, Louisiana will begin invoicing for rebate based on 340B claim level indicators on all claims, both medical and pharmacy. It is imperative that covered entity’s and 340B carve-in pharmacies utilize the correct claim level indicators, detailed below. Additional information regarding the MEF can be found at: https://www.hrsa.gov/opa/updates/2015-october.
3. MEDICAID MANAGED CARE
Section 2501(c) of the Patient Protection and Affordable Care Act (ACA) requires state Medicaid agencies to seek rebates on drugs dispensed by Medicaid managed care organizations (MCO). Louisiana requires that covered entities utilize the same carve-in or carve-out designation for managed care as for FFS Medicaid beneficiaries. Effective October 1, 2025, Louisiana Medicaid is transitioning from a single Pharmacy Benefit Manager (PBM) for all the Medicaid MCOs to each MCO utilizing their own PBM. All six MCOs will have their own BIN, PCN, and Group number.
Louisiana Medicaid FFS and MCO BIN, PCN, and group numbers for pharmacy claims:
| Plan Name | PBM Name | BIN | PCN | Group |
|---|---|---|---|---|
| Fee-for-Service | Gainwell Technologies | 610514 | LOUIPROD | n/a |
| Aetna | CVS Caremark | 610591 | MCAIDADV | RX881J |
| AmeriHealth Caritas | PerformRx | 019595 | 06030000 | n/a |
| Healthy Blue | Carelon Rx | 020107 | LA | RX8482 |
| Humana Healthy Horizons | Humana Pharmacy Solusions, Inc | 6010649 | 03191502 | LAM01 |
| Louisiana Healthcare Connections | Express Scripts | 0035858 | MA | 2ENA |
| United Healthcare | Optum Rx | 610494 | 4041 | ACULA |
Payer ID can be utilized to identify managed care Medicaid members’ medical claims.
4 CONTRACT PHARMACIES
HRSA permits covered entities to contract with one or more pharmacies to provide services to the covered entity’s patients in order to increase patient access to 340B drugs.
HRSA expressly prohibits contract pharmacies from dispensing drugs purchased under the 340B Drug Pricing Program to Medicaid beneficiaries unless the covered entity, the contract pharmacy, and the state Medicaid agency have established an arrangement to prevent duplicate discounts (75 FR 10272, March 5, 2010)1 . Louisiana currently has no such agreements in place and requires that all contract pharmacies carve out Medicaid beneficiaries for both FFS and MCO 340B drug claims.
Effective Sept. 12, 2017, pharmacy claims shall deny at Point of Sale (POS) if 340B indicators are on the claim but the pharmacy is not listed in the MEF. These claims shall be filled with regular pharmacy stock, not 340B stock, and billed accordingly.
5 CURRENT BILLING GUIDELINES
For full billing procedures, please refer to each MCO’s provider manual.
Additional Carve-In information is available in the published IB.