Purpose: This document provides information on what to report to the Health Resources and Services Administration (hrsa) when a 340B price is unavailable for a covered outpatient drug. Instructions

340B Price Unavailable

HRSA Notification Template

Purpose: This document provides information on what to report to the Health Resources and Services Administration (HRSA) when a 340B price is unavailable for a covered outpatient drug.
Instructions: Enter data in each field that describe the entity’s experience with the unavailable 340B price(s). Prior to the completion and submission of the form, covered entities are encouraged to directly contact the wholesaler and manufacturer to determine the reason for the unavailability and to better equip HRSA in understanding the circumstance. HRSA follows up on all allegations of non-compliance brought to our attention and will follow-up with all parties once the issue is reviewed.
The completed form should be emailed to HRSA at: 340Bpricing@hrsa.gov

Disclosure options:

1. 
   My signature below serves as consent for HRSA to disclose contact information to the manufacturer(s) in question, if necessary, so the covered entity can be contacted to help resolve the issue in question.
   

Contact’s Name:
Phone Number:
Email Address:
Printed Name of Submitter:
Date:
Submitter’s Signature:

2. 
    Check this box if the covered entity does not want to be disclosed to the manufacturer(s).
   

Field	Description	Enter Data Here
340B entity name, 340B ID, address of entity making report and contact name	Enter the covered entity name, 340B ID, address of the entity making this report, contact information for the person submitting the request, and date of submission	Entity Name:
		340B ID:
		Address:
		Contact Name:
		Contact Phone #:
		Contact Email:
		Notification Submission Date:
NDC Drug Name and Strength Manufacturer	Enter the NDC, drug name and strength, and the manufacturer associated with the product.	NDC	Drug Name & Strength		Manufacturer
Date lack of 340B price was first observed	Enter the calendar date (MM-DD- YYYY) or approximate date when the lack of a 340B price was first observed. Enter NEVER if the 340B price has never been available.	MM	DD		YYYY
Date of last 340B purchase for this NDC	Enter calendar date (MM-DD-YYYY) or approximate date when the product was last available at a 340B price. Enter NEVER if the 340B price has never been available.	MM	DD		YYYY

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