340B Agreement

Between

The Department of Health and Human Services

and

______

(Please indicate provider name)

Tax ID:

HRSA ID:

Medicaid Enrolled NPI(s) that will be used for billing under 340B:

  1. State of Purpose

______(hereinafter referred to as “Provider”) is a private, not-for profit hospital that desires to participate in the pharmacy program under 340B of the Public Health Service Act (42 U.S.C. 256b). In order for the Provider to participate in this program, the Department of Health and Human Services must certify that the Provider is under contract to provide health care services to low income individuals who are not entitled to benefits under Title XVIII of the Social Security Act or eligible for assistance under the State plan of Title XIX of the Social Security Act. This agreement creates such a contract.

This agreement is to be governed by, and written in accordance with, the laws of the State of Maine.

  1. Responsibilities of the Parties
  1. The Provider will:
  1. Provide physician-administered drugs to low-income individuals who are not entitled to benefits under Title VVIII of the Social Security Act or eligible for assistance under the State plan of Title XIX of the Social Security Act.Check one of the following:

☐ Not utilize drugs purchased at 340B contract pricing for dispensing to MaineCare members and will bill the MaineCare program at the existing MaineCare reimbursement methodologies, allowing rebates to be collected.

☐ Utilize drugs purchased at 340B contract pricing for dispensing to MaineCare members disallowing rebates to be collected.

  1. Provide health care to the indigent of the State of Maine, as well as to those not covered by MaineCare or Medicare, at little to no reimbursement, regardless of the individual’s ability to pay and in accordance with the Department’s Division of Licensing and CertificationFree Care Guidelines (10-144 C.M.R. Ch. 150);
  2. Post and provide notice of the availability of free care in accordance with 10-144 C.M.R. Ch. 150, § 1.04.
  3. File and maintain a copy of its Free Care Policy and posted notice with the Department in accordance with 10-144 C.M.R. Ch. 150, § 1.09;
  4. Maintain records of the amount of free care provided in accordance with 10-144 C.M.R. Ch. 150, § 1.08(A);
  5. Report a summary of the amount of free care provided by the Provider as part of its filing of information for purposes of final reconciliation in accordance with 10-144 C.M.R. Ch. 150, § 1.08(B);
  6. Abide by all other provisions of the Department’s Free Care Guidelines (10-144 C.M.R. Ch. 150);
  7. Abide by the 340B regulations;
  8. Provide the Department with such other data as is reasonably necessary to verify compliance with this agreement; and
  9. Notify DHHS if the Provider’s 340B status has changed.

The Provider will provide the following along with this application: (i) a letter certifying that the Provider continues to provide services to low-income individuals who do not qualify for MaineCare or Medicare and to otherwise comply with the terms of this agreement (the “Certification Letter”); and/or (ii) a copy of its most recent Form 990 and any other information or documentation reasonably deemed necessary by DHHS to verify the Provider’s continued compliance with the terms of this agreement (the “Verification Documentation”). In addition, this documentation will be made available to the extent required by DHHS. Please indicate the address where DHHS may direct any request for such Certification Letter or Verification Documentation:

Provider Name: ______

Attn: ______

Address: ______

City: ______State: ______Zip: ______

DHHS shall make a request for such Certification Letter and/or Verification Documentation no more than once per calendar year and shall provide the Provider with no less than sixty (60) days to comply with such request.

  1. The Department of Health and Human Services will:
  1. Accept such commitment on behalf of and to the benefit of the State of Maine and acknowledges the hospital is providing these services at little or no reimbursement.
  2. Electronically certify the form required by the Office of Pharmacy Affairs to confirm that the Provider has such an agreement with the State of Maine.
  1. Duration

The term of this agreement will begin as of the date it is fully executed by the parties below and shall remain in effect for an initial term of five (5) years. This agreement may be terminated by either party upon 90 days written notice.Both parties have the power and authority to enter into and perform its obligations under this agreement.

Date:

(Signature)

Name Printed:

Title:

Provider:

Date:

(Signature)

Name Printed:

Pharmacy Director

Office of MaineCare Services

Version 2.3Updated 4/12/2018 Page 1 of 2